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THE 


STUDENT'S    MANUAL 


OF 


Venereal  Diseases, 


BEING   THE 


University  Lectures  Delivered  at  Charity  Hospital^  B.I., 
during  the  Wiiiter  Session  of  1879-80. 


BY 


F.   R.   STURGIS,  M.D., 


CLINICAL   LECTURER   ON   VENEREAL   DISEASES    IN   THE   MEDICAL    DEPARTMENT   OF   THE 

UNIVEKSITY   OF  THE   CITY   CF    NEW   YORK  ;     ONE  OF  THE    VISITING    SURGEONS 

TO   CHARITY  HOSPITAL,  B.  I.,   DEPARTMENT  OF   VENEREAL   AND   SKIN  ; 

ONE     OF     THE     VISITING     SURGEONS     TO     THE     NEW     YORK 

DISPENSARY,      DEPARTMENT     OF     VENEREAL     AND 

SKIN  ;     MEMBER      OF     THE     NEW     YOKK 

DERMATOLOGICAL     SOCIETY, 

ETC.,      ETC.,      ETC. 


NEW   YORK: 

G.    P.    PUTNAM'S     SONS, 

182  Fifth  Avenue. 
1880. 


\kj^c^o 


Copyright. 

G.  P.  PUTNAM'S   SONS. 

1880. 


THE    STUDENTS 

OF  THE 

Mbdical  Department  of  the  University  of  thb 
City  of  New  York, 

THIS  MANUAL  ON  VENEREAL  DISEASES 
By  their  obliged  Friknd  and  Teacher, 

THE    AUTHOR. 


PREFACE. 


It  has  been  said,  with  much  truth,  that  books  are 
read  in  inverse  proportion  to  their  length,  and  in  pre- 
paring this  Manual  I  have  steadily  kept  the  question  of 
length  in  view. 

Written  for  students  of  medicine,  it  has  been  my  aim 
to  make  the  book  concise,  and  at  the  same  time  prac- 
tical. I  have,  therefore,  as  far  as  possible,  eschewed 
all  mooted  points  in  Venereal  medicine,  and  confine 
myself  to  giving  a  careful,  and  at  the  same  time  con- 
densed, description  of  the  commoner  forms  of  Venereal 
diseases  which  will  fall  to  the  lot  of  the  average  young 
practitioner  to  treat,  together  with  the  most  appro- 
priate remedies. 

How  w^ell  I  have  accomplished  my  task  remains  for 
others  than  myself  to  say.  I  trust,  however,  that  it  will 
satisfy  a  want  which,  from  my  experience  as  a  lecturer 
in  this  branch,  I  know  exists,  and  with  this  hope  I  send 
the  little  Manual  into  the  world  to  take  its  chances, 

i6  West  Thirty-second  Street, 
New  York  City. 


CONTENTS. 


LECTURE  I. 

PAGE 

Simple   Venereal  Ulcer  and    its   Complications — The 

Chancroid, i 

LECTURE  IL 
Treatment  of  the  Chancroid,        .....  14 

LECTURE  in. 
The  Initial  Lesion  of  Syphilis,        .        ,        .        ,        .      28 

LECTURE  IV. 
Syphilides  of  the  Skin  and  its  Appendages,        .        .  44 

LECTURE  V. 
Syphilides  of  Mucous  Membranes— Syphilitic  Adenitis,       64 

LECTURE   VI. 
Syphilis  of  Special  Organs, 73 


VI 11  CONTENTS. 

LECTURE   VII. 

PAGE 

Syphilis  of  the  Nervous  System  and  of  Bone,       .        .      88 

LECTURE  VIII. 
Treatment  of  Syphilis, loo 

LECTURE  IX. 
Infantile  Syphilis  and  its  Treatment,    ....     122 

LECTURE   X. 
Gonorrhcea  of  Both  Sexes, 134 

LECTURE  XI. 
Complications  which  Occur  in  Gonorrhoea,   ,        .        .     144 

LECTURE  XII. 
Treatment  of  Gonorrhoea  and  its  Complications,     .        163 


VENEREAL  DISEASES. 


LECTURE  I. 


SIMPLE  VENEREAL   ULCER  AND  ITS  COMPLICATIONS. 
— THE  CHANCROID. 

Gentlemen  : — Before  calling  your  special  atten- 
tion to  the  cases  which  I  have  brought  from  the  wards 
for  the  purposes  of  illustration,  it  may  not  be  inapt 
to  define  what  is  meant  by  venereal  diseases,  and  to 
set  before  you  the  principal  groups  into  which  they 
are  divided. 

Speaking  broadly,  venereal  diseases  are  those  due 
to,  and  originating  in,  sexual  contact,  and,  although 
many  forms  of  these  diseases  are  transmitted  without 
any  sexual  contact,  as  I  shall  show  you  further  on,  the 
name  may,  for  convenience'  sake,  stand.  They  are  at 
present  divided  into  three  principal  groups  or  divi- 
sions :  Gonorrhcea^  Chancroid,  and  Syphilis.  Each 
is  distinct  and  separate  one  from  the  other,  having 
nothing  in  common  with  each  other,  although  they 
may  all  be  present  upon  the  same  person  at  the  same 


2  VENEREAL  DISEASES. 

time,  and  possessed  of  certain  characteristics  which 
are  more  or  less  pecuHar  to  themselves. 

Of  these  three  diseases,  only  the  last  one,  syphilis, 
is  constitutional ;  the  other  two,  gonorrhoea  and  chan- 
croid, are  local.  Remember,  then,  gonorrhoea  and 
cha7icroid  are  local.  Syphilis  is  not;  it  infects  the 
entire  system. 

In  the  lectures  which  it  was  my  pleasant  duty  to 
give  before  you  in  the  spring  course,  I  dwelt  at  length 
upon  gonorrhoea ;  less  so  upon  chancroid  and  syphi- 
lis, and  this  with  a  purpose. 

Here,  in  the  amphitheatre  of  the  hospital,  I  can  bring 
you  face  to  face  with  cases  of  syphilis  ;  you  can  have 
better  facilities  for  examining  the  cases  for  yourselves 
than  at  the  college,  and  if  you  expect  to  learn,  you 
must  handle  and  examine  the  cases  yourselves  ;  no 
one  else  can  do  so  for  you,  and  the  first  case  I  present 
for  your  consideration  is  a  case  of  chancroid  in  a  male 
subject. 

The  history,  I  regret  to  say,  is  imperfect,  no  un- 
common occurrence  in  cases  coming  into  this  hospi- 
tal ;  but  from  what  I  can  glean  from  him  and  the  rec- 
ord book,  his  sore,  which  you  see  is  a  pretty  large 
one,  came  on  two  or  three  days  after  coitus,  and  was 
at  first  quite  small.  Here  is  a  point  to  which  I  wish 
you  to  attend,  one  of  the  most  important  upon  which 
to  base  your  diagnosis  of  a  chancroid,  and  equally 
noteworthy  as  a  differential  mark  between  this  lesion 
and  the  first  manifestation  of  syphilis — what  is  com- 


VENEREAL    ULCER—CHANCROID.  3 

monly  known  as  chancre.  The  sore  came  on  tzvo  or 
three  days  after  coitus;  in  other  words,  but  a  short 
time  elapsed  between  the  infecting  connection  and  the 
resulting  ulcer.     The  effect  was  almost  immediate. 

When  we  come  to  treat  of  syphilis  we  shall  find  that 
this  is  no  longer  true  ;  an  appreciable  interval  elapses 
between  cause  and  eff*ect ;  what  is  technically  called 
the  period  of  incubation. 

Chancroids,  then,  have  at  the  most  a  very  short  pe- 
riod of  incubation,  sometimes  none  at  all,  and  this  de- 
pends much  upon  the  manner  in  which  the  poison,  or 
virus,  so-called,  is  deposited  beneath  the  mucous  mem- 
branes. If  in  coitus  the  membrane  is  abraded  or  torn, 
the  chancroidal  action  begins  at  once,  while,  on  the 
other  hand,  it  is  delayed  if  the  matter  is  deposited  in  a 
fold  of  mucous  membrane,  or  in  a  follicle  ;  but  even 
then  the  delay  is  one  usually  of  only  thirty-six  to 
forty-eight  hours. 

Another  circumstance  in  the  case  is  worthy  of  re- 
mark ;  the  ulcer  has  increased  in  sise,  at  first  he  says 
it  was  quite  small.  This  denotes,  in  chancroids,  a 
tendency  to  spread  and  become  larger  instead  of  small- 
er, a  tendency  due  to  the  destructive  character  of  the 
poison.  Let  me  say  here  a  word  or  two  about  this 
virus  or  poison.  It  holds,  in  venereal  parlance,  much 
the  same  position  that  the  letters  x,  y,  and  z  do  in  al- 
gebra, it  is  an  unknown  quantity.  No  one  has  yet 
demonstrated  the  existence  of  the  virus  of  chancroid, 
or  of  syphilis,  except  by  the  results  ;  and  on  the  prin- 


4  VENEREAL   DISEASES. 

ciple  that  what  is  non-apparent  is  non-existent,  some 
writers  entirely  deny  the  presence  of  a  virus,  and  claim 
these  two  diseases  as  due  to  some  other  cause.  Be 
that  as  it  may,  the  term  is  one  of  great  convenience, 
and  it  would  be  difficult  to  find  a  good  substitute.  I 
shall  therefore,  in  these  lectures,  retain  it,  and  I  beg 
you  will  remember  that  it  means  an  indefinite  some- 
thing endowed  with  certain  properties,  which  varies 
in  these  two  diseases,  and  produces  different  results. 

To  return  to  our  chancroid.  Two  points  we  have 
brought  out,  and  mark  them  well,  ist,  a  period  of 
incubation,  at  the  most  very  short,  sometimes  absent ; 
and,  2d,  a  tendency  to  destructive  action.  Let  us 
now  examine  the  sore  and  see  what  else  we  find.  We 
notice  ojie  rather  large  ulcer  of  irregular  shape,  un- 
even floor,  a  moderately  copious,  purulent  secretion 
(this  has  been  somewhat  modified  by  treatment),  and 
on  putting  the  ulceration  on  the  stretch  we  observe 
that  it  extends  beyond  the  apparent  edges  of  the  sore. 
I  repeat  apparcjit  edges,  because  this  peculiarity  has  a 
decided  bearing  upon  treatment.  Chancroids  fre- 
quently burrow,  going  along  faster  below  than  they 
do  above,  hence  the  external  aspect  of  the  sore  is  no 
necessary  index  of  its  real  area ;  the  edges  of  the  ul- 
cer are  undermined,  and  if,  in  the  treatment,  you  de- 
cide to  destroy  the  chancroid  by  caustics,  convey  the 
destructive  agent  beneath  the  edges  and  beyond  the  ap- 
parent limits  of  the  sore,  even  into  sound  tissues. 

The  number  and  shape  of  the  ulcers  are  the  next 


VENEREAL    ULCER— CHANCROID.  5 

points  which  invite  discussion.  In  this  subject  there 
happens  to  be  only  one,  but  such  is  not  always  the 
case,  as  witness  this  second  man.  Here  we  find  three 
chancroids  of  various  sizes.  This  multiplicity  may 
be  produced  in  one  of  two  w^ays :  either  as  original 
foci  of  infection,  or  by  inoculation. 

Note,  therefore,  that  the  cJiajtcroid  is  capable  of 
self -propagation  tipon  the  person  having  it,  and  also 
tipon  others  to  whom  the  poison  viay  be  conveyed. 

It  is  eminently  contagions  and  ant o-inocnl able.  I 
shall  call  your  attention  again  to  this  point  when  I 
come  to  speak  of  the  initial  lesion  of  syphiHs  (chan- 
cre). In  shape  the  sore  is  irregular,  owing  partly  to 
the  seat,  on  the  inner  layer  of  the  prepuce  and  the 
fossa  glandis,  and  partly  to  the  natural  tendency 
chancroids  have  of  spreading  irregularly  and  sending 
out  shoots,  but  there  is  often  another  reason.  Sev- 
eral chancroids  may  be  seated  close  to  each  other, 
and,  by  destroying  the  intervening  sound  tissue, 
present  to  view  an  ulceration  with  irregular  scalloped 
edges. 

The  secretion,  as  has  been  already  said,  is  copious 
and  picrulent,  caused  by  the  destruction  of  tissue,  and 
pus,  as  you  know,  is  debris. 

Have  we  explained  all  the  noteworthy  characters 
presented  by  this  chancroid  ?  By  no  means,  for  upon 
handling  it  w^e  are  struck  by  the  fact  that  though  the 
ulcer  is  large  and  angry-looking,  the  tissues  upon 
which  it  is  seated  are  perfectly  supple  and  soft.     And 


6  VENEREAL   DISEASES. 

here  let  me  give  you  a  word  of  warning  as  to  the  use 
of  the  word  soft^  which  has  proved  a  fruitful  cause  of 
misunderstanding.  Better  expunge  the  word  from 
your  venereal  vocabulary  and  call  the  chancroid  a 
simple  venereal  ulcer,  as  contradistinguished  from 
the  initial  lesion  of  syphilis  (chancre),  which  is  termed 
the  specific  venereal  ulcer.  In  the  discussions  which 
in  former  days  have  been  had  upon  the  nature  of 
these  two  ulcers,  it  was  stated  and  generally  believed 
that  no  soft  sore,  /.  ^. ,  one  which  had  no  induration  at 
the  base,  was  ever  followed  by  syphilitic  manifesta- 
tions. This  belief  is  now  proved  to  be  erroneous, 
and  sores  devoid  of  indurated  bases  have  been  the 
precursors  of  secondary  symptoms — in  other  words, 
tJie  initial  lesion  of  sypJUlis  may  be  soft.  The  impor- 
tance of  this  you  will  see  later  on.  If  this  be  true, 
the  inapplicability  of  the  term  to  a  chancroid  is  ap- 
parent, for  a  chancroid  is  never  folloived  by  general 
manifestations^  the  initial  lesion  always  is,  and  this  I 
shall  speak  of  more  fully  later  on.  Do  not  therefore 
call  the  chancroid  the  soft  venereal  ulcer,  but  simple 
venereal  ulcer,  if  you  do  not  wish  to  use  the  word 
chancroid. 

Now,  to  come  back  to  our  chancroid,  which  has 
been  waiting  for  us.  We  find  710  induration  at  the 
base  ;  the  tissue  upon  which  it  is  seated  is  perfectly 
supple  and  yields  readily  to  pressure,  in  a  manner 
entirely  different  from  what  it  does  in  this  third  pa- 
tient, who  is  the  subject  of  an  initial  lesion  and   be- 


VENEREAL    ULCER— CHANCROID,  7 

neath  whose  sore,  on  palpation,  you  can  discover  a 
gristly  hard  substance,  the  nature  of  which  you  will 
learn  more  about  by  and  by.  We  have,  then,  dis- 
covered another  trait  of  a  chancroid,  to  wit,  an  ab- 
sence of  indurated  base  ;  but  remember  this  loses 
some  of  its  diagnostic  importance,  from  the  fact  that 
the  initial  lesion  (chancre)  sometimes  presents  the 
same  peculiarity. 

Before  passing  to  the  next  point  let  me  sketch  upon 
the  blackboard  the  salient  features  of  a  chancroid, 
such  as  we  have  discovered  upon  the  cases  examined 
to-day.     They  are  these  : 

Absence,  or  at  most  a  very  short  period  of  incuba- 
tion. 

Tendency  to  spread  irregularly  in  size  and  depth. 

Tendency  to  undermining  of  the  walls  of  the  ulcer. 

Copious  purulent  secretion. 

Contagious  and  auto-inoculable  character  of  the 
pus,  thus  producing  multiple  sores. 

Absence  of  induration  of  the  base  of  the  ulcer. 

Thus  far  we  have  studied  the  chancroid  in  its  sim- 
plest form.  We  will  now  consider  the  complications 
most  liiable  to  occur  with  this  disease. 

The  first  and  the  one  most  intimately  associated 
with  the  chancroid,  is  the  bubo  or  swelling  of  the 
glands,  usually  those  of  the  groin.  This  is  due  to 
two  causes  :  the  first  being  sympathetic  inflammation; 
the  second  and  most  serious,  absorption  of  the  chan- 
croidal matter  from  the  ulcer,  by  the  lymphatics. 


8  .  VENEREAL  DISEASES. 

The  two  subjects  I  bring  before  you  illustrate  these 
points  beautifully.  This  first  case  has,  as  you  see, 
a  large,  indolent,  brawny  swelling  in  his  right  groin; 
and  upon  his  penis  he  still  bears  a  chancroid,  but  in 
the  stage  of  repair.  Number  two  also  has  a  chan- 
croid seated  close  to  and  invading  the  frsenum,  but 
in  his  groin  we  find  a  different  condition  of  things  to 
what  we  did  in  number  one.  Here  we  find  an  open 
ulceration  presenting  an  uneven,  grayish  floor,  evert- 
ed and  undermined  edges,  and  secreting  an  abundant 
amount  of  pus,  recalling  to  mind  the  characteris- 
tics of  the  chancroid  already  presented  to  you.  In- 
deed, you  would  be  right  to  call  it  a  chancroid,  for 
such  it  is  ;  caused  by  the  absorption  of  the  chan- 
croidal matter  through  the  chain  of  lymphatics,  and 
deposited  in  the  nearest  glands  (in  this  case  the  in- 
guinal), there  to  produce  a  similar  condition  of  affairs 
to  what  obtains  in  the  original  ulcer.  In  other  words, 
you  have  here  a  typical  chancroidal  bubo,  pure  and 
simple.  These  two,  then,  represent  the  varieties  of 
bubo  found  with  a  chancroid  ;  the  first  one,  a  bubo 
from  sympathy,  which  frequently  does  not  suppurate, 
and  if  it  does,  furnishes  laudable  healthy  pus ;  the 
second  one,  the  true  chancroidal  bubo,  due  to  absorp- 
tion of  the  matter  from  the  ulcer,  which  invariably 
ulcerates  and  presents  subsequently  the  appearance  of 
a  cJi aneroid — indeed,  is  a  cJiancroid. 

There  are  two  other  points  to  which  I  wish  to  call 
your  attention  :  the  diffused  brawniness  of  the  sur- 


VENEREAL    ULCER— CHANCROID.  9 

rounding  tissues  in  both  cases,  and  the  side  of  the 
body  upon  which  the  buboes  are  seated. 

The  glands  themselves  do  not  seem  to  be  the  only 
parts  affected ;  the  circumglandular  tissue  is  involved 
as  well,  presenting  a  thickened  doughy  mass  in  which 
the  glands  can  be  indistinctly  felt.  Note  this  well,  I 
pray,  for  when  you  come  to  handle  cases  of  syphilis 
you  will  find  a  very  opposite  condition  of  things  ; 
the  glands  will  not  be  fused  together  nor  with  adja- 
cent tissue,  but  they  will  be  distinct,  well  marked y 
and  indurated. 

The  other  point  is  this  :  in  the  second  case  the 
bubo  is  seated  upon  the  groin  opposite  to  the  side 
of  the  penis  upon  which  the  chancroid  is;  in  number 
one  it  is  upon  the  same  side.  The  cause  is  the  po- 
sition of  the  ulcer.  Deduce  then  the  following  rule  : 
Bilboes  are  usually  seated  upon  the  same  side  of  the 
body  as  the  ulcer  zvhlcJi  causes  them,  except  wJien  it 
(the  ulcer)  is  seated  upon  the  fr cerium ^  when  they  will 
be  frequently  found  upon  tJie  opposite  side.  The  same 
is  true  when  the  chancroid  in  the  female  is  seated 
tipoji  the  ''  fourchettCy''  and  this  is  due  to  the  decussa- 
tion of  the  lymphatics  at  these  tzvo  points. 

In  all  the  cases  I  have  shown  you,  the  lesion  has  been 
seated  upon  the  mucous  membrane  of  the  genitals. 
This  is  its  usual  seat,  but  it  may  be  met  with  upon 
the  skin  of  various  parts  of  the  body,  such  as  the  face, 
the  fingers,  and — as  I  have  seen  in  one  case — in  the 
throat.     Such   places  are  not  common  seats  of  the 


lO  VENEREAL  DISEASES. 

chancroid,  so  you  may  always  suspect  the  nature  of 
a  sore  when  located  on  the  parts  I  have  just  men- 
tioned ;  it  is  much  more  likely  to  be  syphilitic ;  at 
any  rate,  always  bear  that  point  in  mind. 

The  course  of  a  chancroid  is  always  destructive, 
and  if  not  properly  treated  may  result  in  severe  dis- 
figurement and  loss  of  tissue. 

This  is  especially  the  case  when  the  chancroid  is 
seated  upon  the  frsenum,  or  in  the  urethra  just  within 
the  meatus  urinarius.  In  the  former  place,  perfora- 
tion and  destruction  of  the  frsenum  is  to  be  looked 
for;  and  what  will  perhaps  surprise  you,  is  a  greater 
loss  of  tissue  than  you  had  at  first  counted  upon,  for 
here,  particularly,  the  burrowing  tendency  of  the 
chancroid  is  shown,  and  long  before  the  fraenum  is 
ulcerated  through,  the  sore  has  attained  to  large  di- 
mensions. In  the  latter  place  (the  urethra)  the  sore 
extends  rapidly,  is  difficult  of  treatment  from  its 
comparative  inaccessibility,  and  upon  cicatrization 
produces  partial  stenosis  of  the  meatus,  requiring  sub- 
sequent surgical  treatment. 

As  I  have  already  stated,  these  ulcers  have  a  ten- 
dency to  spread,  and  from  their  facility  of  auto-inoc- 
ulation, to  multiply  ;  hence  the  treatment,  to  be  effec- 
tive, must  he  prompt  diXid  thoroicgh.  Under  proper 
care  the  copious  purulent  secretion  is  diminished, 
the  gray  floor  disappears,  granulations  spring  up  over 
the  surface  of  the  sore,  and  the  undermined  edges  fill 
up  level  with  the  walls  of  the  ulcer.     But,  bear  this 


VENEREAL    ULCER— CHANCROID.  II 

point  in  mind  :  a  chancroid  is  dangerotis  tip  to  the 
very  moinejit  of  its  complete  cicatrization  /  7to  matter 
how  superficial  or  simple  it  may  look^  do  not  remit  the 
thoroughness  of  your  treatment  nntil  cicatrization  is 
complete.  I  have  seen  chancroids  almost  well  relapse 
(without  afresh  infection)  from  just  that  want  of  care, 
the  slight  discharge  remaining  being  sufficient  to  re- 
inoculate  the  almost  cicatrized  sore. 

Phagedena  is  another  and  perhaps  the  worst  acci- 
dent which  can  attack  a  chancroid,  and  when  it  be- 
comes serpiginous — that  is,  when  it  extends  in  one 
direction  while  healing  in  another — may  last  for  a  long 
time  (several  years)  and  seem  well-nigh  hopeless  of 
cure.  It  fortunately  is  not  common  in  this  section 
of  the  country  at  least,  and  occurs  in  those  persons 
whose  health  is  broken  down  from  alcoholic  excesses 
or  constitutional  debility,  such  as  scrofula  and  the 
like.  Remember,  that  it  is  due  to  constitutional, 
not  local  causes,  and  to  combat  it  successfully  you 
must  take  your  measures  accordingly.  This  grave 
accident  attacks  not  only  the  chancroid  itself,  but 
the  chancroidal  bubo,  lasts  for  an  indefinite  time,  and 
will  put  you  to  your  trumps  to  cure. 

Before  passing  on  to  the  consideration  of  treat- 
ment, there  are  other  compHcations  to  which  I  wish 
to  direct  your  attention,  to  wit :  phimosis  occurring 
with  chancroid,  and  chancroids  of  the  anus.  You 
already  know  that  the  first  of  these  complications 
occurs  with  syphilis  and  gonorrhoea,  as  well  as  with 


12  VENEREAL   DISEASES. 

chancroids,  and  it  is  important  for  you  to  be  able  to 
know  which  one  of  these  diseases  lurks  behind  the 
constricted  foreskin,  not  only  for  the  diagnosis,  but 
for  treatment.  In  cases  of  clap  and  chancroid  there 
is  a  copious  purulent  secretion  from  beneath  the  pre- 
puce ;  \i\\tm gonorrhxa  this  matter  is  ?iot  auto-inocn- 
lablCy  while  in  chancroid  it  is.  With  a  chancroid  the 
penis  is  much  more  painful,  cedematous,  and  swollen, 
and  the  lymphatics  on  the  dorsum  penis  are  more  apt 
to  be  inflamed  and  tender  than  is  the  case  in  gonor- 
rhoea ;  but  the  crucial  test  is  aiito-inocidation.  If  the 
hidden  ulcer  be  an  initial  lesion,  the  secretion  is  veiy 
scanty y  if  indeed  there  be  any  ;  the  prepuce  is  hard 
and  indurated^  instead  of  being  oedeniatons  and 
doughy y  and  the  secretion  is  not  auto-inoculable. 

Chancroids  of  the  anus  are,  in  the  male  subject, 
very  rare  indeed  ;  and  where  you  find  them,  always 
suspect  sodomy,  and  I  believe  you  will  seldom  be 
wrong.  The  same  is  still  more  true  as  regards  the 
initial  lesion  of  syphilis  (chancre).  But  with  women 
it  is  different.  With  them  anal  and  rectal  chancroids 
are  not  rare,  and  their  presence  does  not  imply  Venus 
prcBpostera.  '  The  secretion  from  the  chancroids  of 
the  female  genitals  naturally  flows  over  the  perineum 
and  anus ;  very  few  feminine  ani  but  are  abraded  ; 
auto-inoculation  occurs,  and  the  thing  is  done,  and  a 
very  nasty  thing,  too.  The  ulcer  extends  in  all  di- 
rections, eats  through  and  neutralizes  the  action  of 
the  sphincter  ani,  producing  incontinence  of  the  bow- 


VENEREAL    ULCER— CHANCROID.  13 

els ;  burrows  up  into  the  rectum  ;  is  continually  irri- 
tated by  retained  fecal  matter ;  is  extremely  difficult 
to  heal,  and,  when  it  finally  does,  nearly  always 
leaves  a  stricture  of  the  rectum  behind  it ;  and  if  to 
that  you  add  phagedena,  a  not  infrequent  complica- 
tion in  broken-down  harlots,  the  picture  is  a  pretty 
dismal  one. 

Chancroids  of  the  female  genitals  differ  in  no  essen- 
tial respect  from  those  of  the  male  in  appearance  or 
course.  Their  usual  seat  is  at  the  vulva  and  introitus 
vaginae  ;  they  are  next  most  frequent  on  the  cervix 
uteri,  and  are  very  rarely  met  with  in  the  vagina  be- 
tween these  points. 

Buboes  in  women  are  not  so  common  as  in  men, 
excepting  when  the  chancroid  is  seated  at  the  *'four- 
chette,"  when  they  follow  the  same  course  of  action 
as  that  already  detailed  in  the  early  part  of  this  lec- 
ture. 


LECTURE    II. 

TREATMENT  ,0F  THE    CHANCROID. 

At  our  last  meeting  we  went  over  the  description 
of  the  chancroid  and  the  comphcations  which  are  its 
most  frequent  concomitants,  reserving  the  question 
of  treatment  to  a  lecture  by  itself.  This,  then,  will 
form  the  subject  of  to-day's  lesson,  and,  at  the  outset, 
I  want  to  impress  upon  your  minds  the  two  cardinal 
points  of  treatment,  which  are,^r^/,  the  arrest  of  the 
virulent  and  destructive  character  of  the  ulcer;  second y 
cleanliness. 

First,  then,  as  to  the  arrest  of  the  virulent  and  de- 
structive character  of  the  ulcer.  This  is  done  either 
by  the  actual  cautery  or  other  caustics,  in  severe 
cases,  and  by  alterative  applications  in  light  ones. 
Of  the  first  division  of  remedies  the  white  iron,  or  the 
galvano-cantery ,  takes  the  front  rank  as  a  destructive 
agent;  next  to  that  comes  the  strong  SJilphuric  acid ; 
third,  chemically  pure  nitric  acid ;  and  fourth,  pure 
carbolic  acid.  A  neat  way  of  using  the  sulphuric  acid 
is  the  method  known  as  Ricord's  carbo-sulphuric 
paste,  which  is  made  by  taking  a  small  quantity  of 
finely-powdered    willow  charcoal,  adding,   drop    by 


TREATMENT  OF    THE    CHANCROID.  1 5 

drop,  enough  of  the  acid  to  make  a  paste  of  the  con- 
sistence of  thick  cream.  This  is  put  on  with  a  porce- 
lain or  glass  spatula,  taki?ig  careiremetnber  the  tinder- 
fnined  edges)  to  carry  the  agent  into  sound  tissue  both 
underneath  and  on  tJie  surface  of  the  edges  of  the  chan- 
croid. Nitric  or  carbolic  acid  may  be  used  in  the 
same  way.  The  advantage  of  this  method  is,  that 
besides  destroying  the  virulent  ulcer,  it  makes  a  firm 
dressing  by  the  drying  of  the  charcoal  on  evaporation 
of  the  acid,  which,  on  dropping  off  at  the  end  of  sev- 
eral da5^s,  reveals  the  chancroid  almost  if  not  entirely 
healed  up.  If  you  prefer  to  use  the  acids  in  a  fluid 
form,  then  some  subsequent  dressing  must  be  used, 
and  of  all  dressings  I  infinitely  prefer  the  dry  to  the 
wet.  One  of  the  best  preparations  is  iodoformy?;^^/;/ 
powdered,  either  alone  or  in  combination,  thus: 

^  .     Pulv.  iodoformi i  part. 

Lycopodii 2  parts. 

Triturate  well — apply  locally. 

The  lycopodium  has,  probably,  only  a  mechanical 
action,  but  it  absorbs  fluid  very  readily,  while  the 
iodoform  acts  as  a  local  stimulant  and  alterative.  An- 
other good  prescription  is, 

^.    Pulv.  iodoform. 

Pulv.  ac.  tannic,  p,  ce. 
Triturate  and  use  locally. 

This  is  more  astringent  than  the  other. 


1 6  VENEREAL   DISEASES. 

No.  3.  is  useful  when  the  ulcer  looks  flabby  and  in- 
dolent. 

I^ .    Pulv.  iodoform 3  i. 

Zinci  sulphat gr.  v. 

Pulv.  ac.  tannic 3  i. 

M.    Triturate.     For  local  use. 

One  serious  objection  to  iodoform  in  private  prac- 
tice is  the  strong  and  pungent  smell  which  it  has. 
Many  attempts  have  been  made  to  overcome  this,  and 
Dr.  Bronson  of  this  city  speaks  highly  of  combining 
the  iodoform  with  some  essential  oil,  such  as  pepper- 
mint, rosemary,  and  the  like,  which  he  claims  over- 
comes the  odor  without  interfering  with  the  alterative 
action  of  the  drug.^ 

Should  you  from  any  cause  decide  to  use  a  wet  in 
preference  to  a  dry  dressing,  you  will  find  the  formu- 
lae which  I  give  below  as  good  as  any  you  can  use  : 

5. .     Ac.  carbol.  cryst 3  i--  3  ij. 

Aquae §  viij. 

M. 

Or— 

I^ .     Zinc,  sulphat gr.  v.-xx. 

Aquae 3  ij. 

*  The  following  is  the  formula  : 

3 .     lodoformi  pulv 3  i. 

Mucilag.  acac, 

Glycerinse SS  gtt,  x. 

01.  menth.  pip.  (seu  neroli  seu  caryophylli) gtt.  i. 

Misce. 


TREATMENT  OF   THE   CHANCROID.  1 7 

This  latter  application  is  an  excellent  dressing  where 
the  ulcer  looks  flabby  and  indolent.  The  strength  of 
20  grs.  to  I  ij.  should  only  be  used  when  the  ulcer  is 
unattended  with  inflammation  ;  if  there  be  any,  the 
weaker  solution  is  better. 

Another  very  excellent  dressing  for  chancroids  is 
a  weak  solution  of  nitric  acid,  thus  : 

15. .     Acidi  nitrici  c.  p , 3  i- 

Aquas |  viij. 

M. 

You  observe  that,  in  the  list  I  have  written  for  your 
use,  the  nitrate  of  silver  does  not  appear.  This  may 
appear  strange,  for  the  lunar  caustic  is  the  one  par 
excellence  which  is  daubed  over  any  suspicious-look- 
ing ulcer.  But  I  say  to  you,  don't  use  it  if  you  mean 
to  use  a  caustic.  Nitrate  of  silver  is  not,  in  the  true 
sense  of  the  term,  a  caustic  ;  its  action  is  very  super- 
ficial, inasmuch  as  it  quickly  forms,  with  the  albumen 
of  the  tissues,  an  insoluble  albuminate  of  silver,  and 
it  cannot  destroy  deeply  or  thoroughly  as  do  the  sul- 
phuric and  nitric  acids.  Confine  its  use ^  then,  to  those 
cases  where  you  desire  to  stimulate  indolent,  slozvly- 
healing  chancroids  /  when  yo7c  zvish  to  destroy,  select 
some  other  agent. 

The  above  rules  for  treatment  are  good  where  the 
lesion  is  exposed  and  accessible,  but  how  shall  we  act 
in  cases  of  chancroids  concealed  either  in  the  urethra 
or  behind  a  phimosis  ?     The  first  object  to  be  attained 


1 8  VENEREAL  DISEASES. 

is  to  relieve  the  phimosis,  the  second  to  check  the  ex- 
tension of  the  chancroid.  For  the  first  point  you  will 
find  nothing  better  than  freely  bathing  the  genitals  in 
hot  water  (as  hot  as  the  patient  can  bear  it,  even  to 
the  point  of  faintness)  several  times  daily,  and  at  night 
wrapping  the  penis  up  in  the  following  lotion: 

3.     Liquoris  plumb,  subacetat., 

Tinct.  opii aa  ^  i. 

Aquae  ad |  viij. 

M.     S, — Local  use. 

In  conjunction  with  the  hot  bathing,  subpreputial 
injections  should  be  made  several  times  during  the 
day  with  a  solution  of  carbolic  or  nitric  acid  in  the  fol- 
lowing manner  :  With  a  Taylor's  syringe,  which  is 
nothing  but  a  flat-billed  syringe,  made  of  hard  rub- 
ber, throw  up  hot  water  between  the  prepuce  and 
glans  penis  until  the  return  flow  shows  no  shreds  or 
fibres;  then,  with  the  same  instrument,  inject  carefully 
two  syringesful  of  either  of  the  following  solutions  : 

I^ .    Ac.  carbol.  cryst 3  ss.-  3  i- 

Aquje I  viij. 

Or— 

I^ .    Ac.  nitric,  c.  p 3  ss. 

Aquae |  viij. 

taking  care  that  the  fluid  reaches  well  back  to  all  por- 
tions of  the  fossa  glandis.  After  this  is  done,  a  small 
dossil  of  lint  or  prepared  cotton   should   be  lightly 


TREATMENT  OF   THE   CHANCROID,  19 

placed  at  the  orifice  of  the  prepuce,  between  it  and  the 
glans  penis.  This  plan  of  procedure  should  be  stead- 
ily persevered  in  until  the  prepuce  can  be  retracted 
and  the  glans  penis  freely  exposed,  when  the  chan- 
croids can  be  treated  as  already  advised. 

Suppose  this  happy  result  not  attainable,  what  then 
must  we  look  for  ?  It  may  happen  that  the  swelling 
and  inflammation,  instead  of  subsiding,  increases  ;  the 
entire  organ  becomes  enormously  cedematous  and 
purple,  threatening  gangrene,  and  it  is  evident  that  a 
very  serious  condition  of  things  obtains  ;  in  fact,  gan- 
grene will  rapidly  come  on  unless  active  measures  are 
adopted  to  check  it. 

Sometimes,  happily  very  rarely,  the  sphacelus  at- 
tacks a  large  portion  of  the  penis,  causing  very  seri- 
ous consequences  ;  but  usually  it  is  confined  to  nar- 
rower limits,  and  Nature  is  satisfied  when  she  has  re- 
lieved the  prepuce  and  re-established  the  circulation. 
This  she  does  in  the  following  manner  :  One  or  more 
spots  of  a  purple  hue  appear  upon  the  swollen  pre- 
puce at  points  corresponding  with  the  imprisoned 
glans  penis  beneath  ;  these  spots  get  darker  in  color, 
extend  and  coalesce,  and  by  becoming  gradually  thin- 
ner admit  of  the  exit  of  the  glans  penis  through  the 
opening,  safe  and  sound.  The  redundant  and  useless 
foreskin  may  be  subsequently  removed  by  operation. 
This  is  the  course  where  everything  goes  on  smooth- 
ly and  safely,  but  sometimes  active  surgical  interfer- 
ence  becomes   requisite.      This  happens   when   it   is 


20  VENEREAL   DISEASES. 

evident  that  extensive  loss  of  tissue  must  super- 
vene before  the  imprisoned  glans  penis  can  be  Hb- 
erated,  and  here  you  have  to  carefully  choose  be- 
tween two  evils.  You  must  overcome  the  constric- 
tion by  cutting  through  it ;  but  remember  what  I  have 
already  told  you  about  the  contagious  character  of 
the  chancroid.  The  cut  edges  of  the  incision  are  sure 
to  become  inoculated^  Jience  I  advise  you  not  to  operate 
tinless  it  be  done  to  save  your  patient  from  sometJiing 
worse  tJian  an  extension  of  the  chajtcroid.  But  if  you 
have  to  do  it,  let  me  give  you  one  or  two  hints  as  to 
the  way.  Carry  your  director  between  the  prepuce 
and  the  glans  penis  in  the  median  line  *  (be  careful 
not  to  pass  it  into  the  urethra),  and  then  slit  the  fore- 
skin well  up  to  the  fossa  glandis  ;  that  will  liberate 
the  glans,  and  on  retracting  the  prepuce,  search  for 
the  chancroids.  Destroy  them  at  07ice\v\\.\\.  one  of  the 
strong  caustics  already  mentioned,  and  at  the  same 
time  cauterize  the  cut  edges  of  the  zvound  you  have 
made.  The  subsequent  dressing  will  be  similar  to 
what  I  have  already  advised.  The  "  dog's  ears  "  left 
by  the  operation  may  be  subsequently  removed  by 
circumcision,  but  not  until  the  chancroids  have  entire- 
ly healed. 

If  the  chancroid  be  in   the   urethra,  your  tactics 
must  vary  a  little.     When  situated  close  to  the  mea- 

*  The  incisions  are  sometimes  made  upon  the  two  sides  instead  of  the 
median  line.  This  variety  of  incision  is  better  if  the  foreskin  is  very 
much  thickened. 


TREATMENT  OF    THE    CHANCROID.  21 

tus,  separation  of  the  lips  will  expose  the  sore,  which 
may  be  cauterized  and  dressed  with  one  of  the  wet 
preparations  previously  mentioned.  When  beyond 
reach,  upon  separation  of  the  lips  of  the  meatus,  you 
must  use  a  weak  injection  of  carbolized  *  or  other- 
wise medicated  fluid,  and  afterward  insert  a  dossil 
of  lint  or  cotton,  wet  with  the  same  solution,  within 
the  urethra. 

Contraction  of  the  meatus  left  upon  cicatrization 
of  the  chancroid  may  be  remedied  by  slitting  the 
meatus  with  a  bistoury  or  a  meatotome. 

Such  dressings — indeed  all  dressings  for  the  treat- 
ment of  chancroids — should  be  made  three  or  four 
times  daily,  at  the  least. 

When  the  chancroid  is  seated  at  the  fraenum, 
threatening  perforation,  do  not  wait  for  the  ulcer  to 
eat  its  way  through,  but  anticipate  matters  by  cut- 
ting the  fraenum  yourself.  If  hemorrhage  result  from 
the  small  artery  seated  in  the  fraenum,  tie,  if  requi- 
site, but  torsion  will  check  bleeding  in  the  majority 
of  cases.  You  must  then  treat  the  chancroid,  which 
will  often  turn  out  much  larger  than  you  at  first  sup- 
posed, by  the  rules  I  have  already  given  you. 

As  regards  the  treatment  of  buboes,  the  rules  are 
simple  and  easily  laid  down.  Until  the  bubo  breaks 
you  cannot  be  certain  whether  it  is  a  simple  or  a 
chancroidal  one  you  have  to  deal  with.     Your  first 

*  Ac.  carbol.,  \,  \  gr.  to  aq.   |  i. 


22  VENEREAL   DISEASES. 

efforts,  therefore,  should  be  to  cause  absorption  ;  if 
the  bubo  is  non-virulent,  you  are  often  successful ; 
but  if,  on  the  other  hand,  the  bubo  is  due  to  the  ab- 
sorption of  matter  from  the  chancroid,  you  will 
find  the  swelling  extend,  the  bubo  rapidly  become 
softer,  and  fluctuation  more  pronounced.  The  mo- 
ment you  are  sure  of  JliLctuatioJt,  open  the  bnbo,  and 
this  for  a  twofold  reason.  Pus,  in  my  experience, 
whether  due  to  virulent  or  non-virulent  buboes,  is 
not  absorbed  when  once  it  begins  to  form,  and  under 
these  circumstances  it  is  much  better  evacuated.  If 
the  bubo  be  a  simple  one,  the  moment  the  pus  is  let 
out  the  bubo  heals  up  ;  if,  on  the  other  hand,  it  be 
virulent,  the  sooner  you  know  it  the  better  for  your 
patient.  But  we  will  suppose  that  the  bubo  has  not 
as  yet  shown  any  fluctuation  ;  what  methods  shall  we 
adopt  to  prevent  the  formation  of  pus  ?  Four  ;  viz., 
leeches,  rest,  compression,  and  the  local  application 
of  the  fmcture  of  iodine.  This  latter  must  be  ap- 
plied at  least  once  every  day  up  to  the  point  of  vesi- 
cation, and  as  soon  as  this  is  accomplished  you  will 
find  the  employment  of  the  emplastrum  plumbi  of 
service.  Compression,  if  you  can  persuade  your 
patient  to  go  to  bed,  can  be  best  obtained  by  placing 
a  bag  of  small  shot,  weighing  from  two  to  four  pounds, 
or  a  brick  wrapped  in  flannel,  directly  upon  the  swell- 
ing ;  if  your  patient  will  not  keep  on  his  back,  use  a 
layer  of  compressed  sponge  and  a  spica  bandage, 
which  wet  as  soon  as  it  is  applied,  when  you  will  get 


TREATMENT  OF   THE   CHANCROID.  23 

even  and  firm  compression  from  the  swelling  of  the 
sponge.  Should  your  attempts  at  resolution  fail  and 
suppuration  threaten,  favor  it,  as  far  as  possible,  by 
the  application  of  poultices. 

A  word  or  two  with  regard  to  the  application  of 
leeches,  should  you  deem  them  requisite.  Always 
place  them  at  some  distance  from,  and  never  on  the 
bubo.  Do  not  forget  this  hint,  else  you  will  run  the 
risk  of  inoculating  sound  tissue  from  the  leech  bites, 
if  the  bubo  should  prove  to  be  chancroidal.  It 
is  seldom  that  leeches  are  of  much  service,  and  I 
should  advise  you  to  be  chary  of  their  use  ;  they 
are  not  superior  to  the  other  methods  I  have  men- 
tioned. 

The  bubo  is  now  ripe,  and  is  ready  for  the  knife  ; 
how  is  it  to  be  opened  ?  I  prefer  doing  so  by  an  in- 
cision parallel  with  the  long  axis  of  the  body  first, 
and  then,  if  requisite,  carry  the  cut  upward  and 
downward  in  the  direction  of  Poupart's  ligament. 
Lay  sinuses  open  wherever  you  find  them,  if  you  hope 
to  make  a  speedy  and  permanent  cure.  After  the 
bubo  is  thoroughly  opened,  stanch  the  bleeding 
(exposure  to  the  air  will  suffice  in  most  cases  ;  if  not, 
use  ice-cold  compresses),  and  in  cases  of  simple  bu- 
boes dress  the  wound  with  a  weak  carbolized  lotion 
applied  on  cotton  or  lint.  If,  however,  the  bubo  be 
chancroidal,  cauterize  it  first  according  to  the  direc- 
tions already  laid  down  for  cauterizing  chancroids, 
and  make  what  subsequent  dressings  you  deem  ad- 


24  VENEREAL  DISEASES. 

visable,  carefully  packing  the  material  well  beneath 
the  undennmed  edges. 

An  honest,  free  incision  is,  I  believe,  nine  times  in 
ten  the  best  and  quickest  way  to  treat  these  lesions, 
but  I  will  mention  to  you  two  other  methods  in 
vogue.  One  is  by  aspiration  —  i.e.,  exhausting  the 
bubo  of  its  contents  by  suction  with  Dieulafoy's  as- 
pirator, or  the  American  modifications  of  his  instru- 
ment. 

The  other  is  by  breaking  up  the  bubo  —  i.  e.^ 
churning  its  contents  with  a  blunt-pointed  bistoury 
—  2^  small  incision  having  first  been  made  to  admit  the 
entrance  of  the  bistoury.  Both  of  these  methods 
are,  of  course,  only  applicable  to  the  non-virulent 
bubo,  and  even  here  I  think  other  methods  are  pref- 
erable. 

If  internal  treatment  be  thought  worthy  of  trial,  it 
must  be  borne  in  mind  that  it  is  for  its  tonic  effect 
more  than  anything  else  that  it  is  used.  Only  one 
remedy  is  given  with  the  object  of  checking  suppura- 
tion, and  that  is  the  sulphide  of  calcium,  which  may 
be  administered  as  follows  : 

3 .   Calcii  sulph A  g^- 

Mucilag.  acac q.  s. 

M.    In  one  pill ;  of  these,  3  to  6  daily. 

A  very  neat  way  of  giving  it  is  as  a  compressed 
tablet,  made  with  the  sugar  of  milk,  which  can  be  ob- 
tained at  most  apothecaries'. 


TREATMENT  OF   THE   CHANCROID.  25 

The  tonics  most  in  use  are  the  ferrum  sulph.  exsic- 
cat.  gr.  i.-iij.,  or  the  fer.  pulv.  gr.  i.-ij.  in  pill  form 
three  times  daily  ;  the  sulphate  of  quinine,  or  dextro- 
quinine,  gr.  ij.-iij.  three  times  daily  ;  and  ol.  morrhuae 
31. -|ss.  in  similar  doses.  Of  course  you  will  not 
forget  nutritious  diet  and  stimulants  p.  r.  n.,  but  I 
should  advise  you  to  use  the  latter  as  little  as  you 
can.  /  believe  that  ve7iereal  patients  do  better^  as  a 
rtUe^  ivithoiit  alcohol. 

There  is  one  other  subject  in  connection  with  these 
diseases  which  I  wish  to  discuss  with  you  before  bring- 
ing this  lecture  to  a  close,  and  that  is  the  one  of  phage- 
dena. It  will  be  sufficient  to  recall  to  your  mind  the 
cases  of  the  three  women  which  I  showed  you  a  short 
time  since,  where  the  ulceration  had  crept  over  the 
nates  and  down  the  thighs,  up  the  abdomen  and  along 
the  groins,  breaking  down  the  recto-vaginal  wall  and 
destroying  the  labia  vulvae,  to  impress  upon  you  the 
necessity  of  a  vigorous  treatment.  Remember  what 
I  said  to  you  in  a  preceding  lecture  about  phagedena, 
that  it  was  due  to  co7istittitionaly  not  locaV causes,  and 
this  will  be  the  key-note  of  your  treatment ;  altJiough 
not  to  the  exclusion  of  local  remedies,  your  main 
relia^ice  must  be  upon  internal  ajid  constitutional 
measures.  Foremost  in  this  latter  class  stands  the 
potassio-tartrate  of  iron,  which  Ricord  called  the 
"•  born  enemy  of  phagedena,"  and  which  he  is  in  the 
habit  of  applying  both  topically  and  by  the  mouth. 
Thus, 


26  VENEREAL   DISEASES. 

5-  •      Ferri  et  potas.  tart |  i. 

Aqu^ I  vi. 

M. 

S. — Internally,  in  teaspoonful  doses,  thrice  daily;  also 
for  local  application  p.  r.  n. 

A  strongly  carbolized  lotion  will  oftentimes  be  of 
service  as  a  dressing  in  phagedenic  chancroids,  viz.  : 

^.    Ac.  carbol.  cryst 3  ij.-v. 

Aquae Oi. 

M.     S.— Locally. 

By  far  the  most  frequent  cause  of  phagedena  is  that 
condition  of  the  system  kniown  as  *'  chronic  alcohol- 
ism," and  which  it  should  be  your  aim  to  relieve  as 
far  as  possible.  In  such  cases  you  will  find  the  fol- 
lowing prescription  a  serviceable  one  : 

3 .    Ol.  morrh |  ss. 

Dil.  phosph.  ac Tl^x.-xxx. 

In  one  dose. 

S. — Three  times  daily,  or  oftener  if  necessary. 

This  seems  to  act  by  toning  up  the  depressed  ner- 
vous system  of  chronic  drunkards,  and  giving  the 
body  a  chance  of  combating  the  disease. 

Other  tonics  which  are  suitable  in  such  cases  are 
those  which  I  have  previously  mentioned. 

Among  the  local  dressings,  the  potassio-tartrate  of 
iron  and  the  carbohc  acid  are  the  best,  but  I  wish  to 


TREATMENT  OF    THE   CHANCROID.  27 

say  a  few  words  about  the  destrnctio7i  of  a  phagedenic 
chancroid.  The  only  agents  which  are  of  any  real 
value  for  that  purpose  are  the  hot  iron  and  the  gal- 
vano-cautery  ;  the  other  corrosive  agents  I  have  pre- 
viously mentioned  are  of  little  use.  In  applying 
either  of  these  agents  remember  to  have  the  heat 
tvhite,  not  redy  for  two  reasons  :  first,  because  it  is 
more  effective  ;  second,  because  it  is  less  painful. 
Remember  also  to  carry  the  destruction  of  tissue,  as 
in  the  case  of  the  acids,  beyond  the  diseased  parts. 

These  constitute  the  most  practical  points  in  the 
treatment  of  this  important  affection  ;  and  I  have,  as 
far  as  possible,  confined  myself  to  giving  you  what  I 
have  found  the  most  efficacious  remedies,  without 
cumbering  your  minds  with  a  quantity  of  useless  pre- 
scriptions. 


LECTURE  III. 

THE  INITIAL  LESION   OF  SYPHILIS. 

To-day  we  break  ground  upon  the  most  impor- 
tant venereal  disease  which  can  afflict  mankind,  im- 
portant not  only  from  its  effects  upon  the  original 
bearer  of  the  disease,  but  also  from  the  horrible  con- 
sequences which  may  be  entailed  upon  the  offspring 
of  the  syphilitic  person ;  and  in  dealing  with  syphiHs 
I  shall  try  to  give  you,  as  clearly  and  practically  as  I 
can,  the  chief  points  of  the  disease,  and  in  what  its 
first  symptom,  the  initial  lesion,  differs  from  the 
chancroid. 

In  the  first  place,  let  me  explain  why  I  abandon 
the  name  chancre.  First,  because  it  is  coiifiisi7ig ; 
and  second,  because  it  means  nothing.  The  French, 
English,  and  most  American  writers  call  the  syphi- 
litic sore,  chancre,  and  the  local  venereal  sore  the 
chancroid;  but  the  Germans  expunge  the  word  chan- 
croid from  their  vocabulary,  calling  that  lesion  chan- 
cre, and  our  chancre  the  initial  lesion  of  syphilis  ; 
and  this  multiplying  of  names  is  confusing.  Chan- 
cre, originally  derived  from  cancer,  means  **  some- 
thing which  eats."     Now,  the  initial  lesion  does  not 


THE  INITIAL  LESION    OF  SYPHILIS.  29 

do  this,  and  the  word  chancre  does  not  necessarily 
mean  anything  syphilitic  ;  but  to  say  initial  lesion 
of  syphilis  means  that  it  is  the  first  symptom  of 
syphilis. 

And  bear  this  well  in  mind,  it  is  syphilis  already ;  ^ 
no  local  lesion,  as  was  the  chancroid,  but  the  first 
symptom  of  a  disease  which  is  always  serious,  some- 
times grave  in  its  results,  and  connected  with  other 
symptoms  which  do  not  appear  for  some  weeks  after. 
I  shall  therefore  call  the  first  symptom  of  syphilis  the 
initial  lesion^  and  entirely  abandon  the  word  chancre. 

The  first  case  I  have  to  present  is  of  interest  in 
several  ways  ;  and  before  commenting  at  length  upon 
it,  let  me  give  you  a  {q\\[  points  in  the  history  :  The 
patient,  a  stout,  well-built  young  fellow,  twenty-four 
years  of  age,  was  admitted  to  the  hospital,  November 
7,  1879.  He  says  he  has  had  gonorrhoea  and  chan- 
croid several  times,  but  you  observe  syphilis  is  not  in- 
cluded in  the  category,  A  very  noteworthy  omission. 
Very  rarely  indeed  does  a  patient  contract  syphilis 
more  than  once  in  a  lifetime  ;  chancroid  and  clap  can 
be  caught  ad  libitum.  But  to  go  on  with  the  history  : 
on  the  9th  of  August,  1 879,  he  contracted  the  present 
sore,  thirteen  days,  he  declares,  after  the  connection. 
Here  let  us  pause ;  thirteen  days  after  coitus  the 
sore  breaks  out.  You  remember  what  we  found 
to  be  the  case  in  studying  the  chancroid,  "the  sore 
came  on  two  or  three  days  after  coitus  ;  "  here  it 
is  thirteen  —  four  to  six  times  longer.     Deduce,  then, 


30  VENEREAL   DISEASES. 

this  axiom  :  the  initial  lesion  of  syphilis  is  endowed 
with  a  period  of  i7icnbation  which  is  denied  to  the 
chancroid.  But  there  is  something  still  more  inter- 
esting in  this  thirteen  days'  incubation.  As  a  rule, 
the  incubative  stage  of  the  initial  lesion  is  longer — on 
an  average  21  days;  but  this  period  is  variable.  If, 
then,  we  reckon  21  days  as  the  average  in  such  cases, 
13  days,  the  present  stage  of  incubation,  is  shorter 
than  the  usual  time,  although  not  the  shortest 
recorded.  The  limits  which  are  now  recognized  are 
maximum  98  days,  minimum  10;  and  although  these 
represent  extreme  cases,  bear  the  possibility  of  their 
occurrence  in  mind  in  making  your  diagnosis. 

To  formulate  the  matter  in  a  few  words,  always 
suspect  the  nature  of  a  venereal  sore  which  has  not 
appeared  until  ten  days  or  more  after  coitus. 

The  history  goes  on  to  say  that  ''it  (the  sore)  com- 
menced on  the  under  surface  and  on  the  right  side 
of  the  prepuce,  and  the  soreness,  swelling,  and  in- 
duration came  on  within  four  days.  At  present  he 
has  an  induration  extending  all  over  his  prepuce." 

The  induration,  which  is  very  perceptible,  is  under 
the  finger  of  a  hard,  resilient  character,  entirely  dis- 
tinct and  separated  from  the  surrounding  tissues, 
and  is  seated  upon  a  non-inflammatory  base.  Con- 
trast this  with  what  we  found  in  the  chancroid.  In 
the  latter  the  tissues  were  soft  and  supple  ;  there  was 
710  induration,  and  the  ulcer  was  angry-looking — in- 
flamed, in  other  words.     In  the  initial  lesion  under 


THE  INITIAL  LESION  OF  SYPHILIS.  31 

observation,  the  ulcer,  if  indeed  we  can  call  it  an 
ulcer,  is  very  superficial ;  it  looks  more  like  an  ero- 
sion /  tJie  floor  is  clean  and  red  in  htce,  the  edges*  slo- 
ping and  not  tindernmied. 

Another  point  of  interest  is  the  fact  that  this  vari- 
ety of  venereal  ulcer  does  not  have  any  tendency  to 
spread  nor  to  cat  into  the  tissues,  as  does  the  chan- 
croid ;  indeed  its  whole  course  is  cold  and  slozv,  and 
shows,  nine  times  in  ten,  3. greater  inclination  to  heal 
up  than  to  exte^id — another  point  of  difference  be- 
tween it  and  the  chancroid,  where  we  found  the 
opposite  attributes. 

Besides  this,  we  observe  the  singleness  of  the  lesion 
and  the  scanti^iess  of  the  secretion  as  noteworthy 
conditions  of  difference  between  the  two  varieties  of 
ulcer.  With  regard  to  the  singleness  of  the  lesion, 
you  remember  we  found  in  chancroids  that  multipli- 
city was  not  exceptional,  and  that  this  was  brought 
about  in  two  ways  :  either  as  i^idependent  foci  of  in- 
fection, or  by  auto-inocidation ;  but  in  the  initial 
lesion  of  syphilis  multiple  sores  are  the  exception 
rather  than  the  rule,  and  when  they  occur  it  is  as  in- 
dependent foci  of  infection y  never  from  auto-inocula- 
tion. Bear  in  mind,  then;  that  the  secretions  of  syph- 
ilis cannot  be  inoculated  as  syphilis  tip  on  a  sypJiilitic 
person. 

The  nature  of  the  secretion  is  also  deserving  of  a 
few  words  ;  it  is  tJiiji  and  scanty,  not  abundant  and 
purulent,  as  we  find  it  in  chancroids,  and  unless  the 


32  VENEREAL  DISEASES. 

ulcer  is  irritated  from  some  cause,  never  becomes 
ptirident. 

I  wish  now  to  call  your  attention  particularly  to 
the  induration,  for  this  is  a  very  important  point, 
and  one  upon  which  too  much  stress  cannot  be  laid. 
Whenever  this  symptom  is  found  clearly  and  well 
fnarkedy  it  is  of  value  as  stamping  the  lesion  with  a 
character.  But  there  are  many  cases  in  which  the 
induration  is  very  thin  and  slight  (parchment  indura- 
tion) ;  nay  more,  where  the  induration  is  entirely 
wantijig.  Yet  the  sore  has  not  changed  its  nature  ; 
it  is  still  syphilis,  and  will  be  followed  by  secondary 
sympto7ns  as  certainly  as  is  the  hard  variety.  This  is 
why  I  urged  you,  when  speaking  of  the  chancroid, 
to  abandon  the  use  of  the  word  **  soft ;  "  for  if  you  re- 
gard the  soft  sore  as  the  one  which  is  par  excelle7ice 
local,  and  does  not  infect  the  constitution,  what  are 
you  going  to  say  of  the  sore  which  does  contami- 
nate, or,  to  be  more  strict,  which  is  the  first  symptom 
of  systemic  contamination,  yet  which  is  "soft"? 
Pray  what  does  the  name  tell  you  ?  Nothing ;  but 
chancroid  and  initial  lesion  do  mean  something ; 
they  tell  you  that  the  first  is  a  local  disease,  the  sec- 
ond a  constitutional  one. 

The  term  *'  hard  sore  "  is  also  objectionable,  be- 
cause the  hard  sore  means  syphilis  in  contradistinc- 
tion to  the  "  soft  sore,"  which  means  the  opposite  ; 
and  yet  some  soft  sores  are  syphilis.  No  !  I 
think   the   names  I   give  you  are   the  best ;   \{  you 


THE  INITIAL  LESION  OF  SYPHILIS.  33 

know  better  ones  adopt  them  ;  if  not,  use  these  with 
me. 

Let  me  then  give  you  another  formula  : 

The  initial  lesion  of  syphilis  is  usiLally  indurated ; 
when  present^  this  is  of  great  value  ;  hut  its  absence^ 
tvhich  sometimes  happens ^  does  not  change  the  nature 
of  the  lesion  ;  it  still  remains  syphilis.  When  the 
indiiration  is  absent^  the  diagnosis  has  to  be  fnade 
from  other  characteristics. 

We  will  now  pass  on  to  study  the  condition  of  the 
glands  in  the  commencing  stage  of  syphilis,  and  here 
we  shall  find  many  points  of  difference  between  the 
initial  lesion  and  the  chancroid. 

To  go  back  a  httle ;  you  remember  in  studying 
the  chancroid  we  found  that  the  inguinal  glands  were 
thickened  and  brawny  —  confounded,  so  to  speak, 
with  the  surrounding  tissues,  in  such  a  manner  as  to 
make  a  doughy  mass,  which  showed,  moreover,  de- 
cided inflammation.  Turn  to  the  cases  before  us, 
and  what  do  we  find  ?  The  glands  in  the  groin  are 
enlarged,  it  is  true,  but  they  are  perfectly  distinct 
from  one  another ;  they  roll  about  under  the  skin 
freely  and  easily.  When  handled  they  are  not  fused 
together  nor  with  circumjacent  tissue,  as  is  the  case 
with  the  chancroid,  and  they  are  painless. 

Could  anything  be  more  opposite  than  these  two 
kinds  of  bubo  ;  yet  this  is  not  all.  Syphilitic  buboes 
rarely  suppiir ate ;  when  they  do,  it  is  from  some  other 
cause  than  the  syphilis — generally  from  debility  or  an 


34  VENEREAL   DISEASES. 

enfeebled  constitution,  and  the  pus  they  furnish  is 
laudable  and  incapable  of  conveying  the  disease  either 
to  the  bearer  of  the  lesion  or  to  others  ;  in  other  words, 
they  are  simple  abscesses,  such  as  you  are  liable  to 
meet  with  in  any  person  who  is  run  down  in  health. 
Neither  are  they  dependent  upon  the  site  of  the  ini- 
tial lesion,  but  are  met  with  on  both  sides  of  the  body, 
and  are  due  to  the  systemic  poisoning  which  has 
occurred — to  the  same  cause  which  has  produced  the 
initial  lesion  itself,  and  not  to  absorption  of  matter 
fro7n  the  nicer. 

When  I  come  to  speak  of  the  subsequent  syphilitic 
symptoms,  I  shall  show  you  how  the  glands  over  the 
body  are  similarly  enlarged — what  is  called  the  ade- 
nitis universalis  sypJiilitica. 

Of  the  initial  lesion  of  syphilis,  there  are  several 
varieties;  the  archetype,  sometimes  called  the  Hun- 
terian  induration,  you  have  already  seen.  You  can 
tell  it  as  far  as  you  can  see  it,  and  it  is  unmistakable, 
but  unfortunately  it  is  not  always  present.  Some- 
times the  initial  lesion  has  but  a  thin  disk-like  layer 
of  induration  beneath  it,  which  gives  to  the  finger  the 
sensation  of  a  slight  layer  of  parchment  beneath  the 
skin  or  mucous  membrane — the  "  parchment  indura- 
tion "  which  I  have  already  brought  to  your  notice ; 
and  again,  very  rarely  it  is  true,  there  may  be  no  in- 
duration at  all.  The  ulceration  in  the  initial  lesion  is 
usually  very  superficial,  and,  when  seated  upon  a  mark- 
edly indurated  base,  is  raised  above  the  surrounding 


THE  INITIAL  LESION  OF  SYPHILIS.  35 

tissue  ;  it  is  then  known  as  the  ulcus  elevatitm,  and 
again  it  may  be  a  mere  erosion  which,  conjoined  with 
Httle  or  no  induration,  is  very  puzzHng,  and  apt  to  mis- 
lead the  surgeon  as  to  its  true  character.  Beware  of 
such  ;  do  not  be  in  a  hurry  to  pronounce  positively  on 
the  nature  of  any  such  lesion,  but  suspend  judgment, 
else  you  may  make  an  awkward  mistake  by  calling  a 
given  lesion  innocent,  which  a  few  weeks  later  will 
be  followed  by  a  general  outbreak  upon  the  skin  and 
mucous  membranes.  In  addition,  the  initial  lesion 
has  no  destructive  tendency,  no  undermined  edges, 
no  gray  floor  ;  on  the  contrary,  it  has  a  red  granula- 
ting appearance,  with  oftentimes  a  dark  spot  in 
the  centre,  and  is  prone  to  bleed  readily  upon  hand- 
ling. 

In  those  cases  where  the  initial  lesion  itself  gives 
little  or  no  information,  appeal  to  the  chain  of  glands 
nearest  to  the  lesion.  You  will  seldom  find  them  in- 
tact, and  their  induration  will  often  help  you  to  a 
diagnosis. 

Let  me,  before  going  further,  make  in  tabular  form 
a  comparison  between  the  initial  lesion  and  the  chan- 
croid : 


CHANCROID. 

Little  if  any  period  of  incuba- 
tion. 

Destructive,  with  tendency  to 
spread. 

Edges  undermined. 


INITIAL   LESION. 

Decided  period  of  incubation. 

Not    desti'uctive ;  tends  to  heal 
rapidly. 

Edges  sloping,  not  undermined. 


3^  VENEREAL   DISEASES. 

CHANCROID.  j  INITIAL   LESION. 

Copious,  purulent  secretion.  '      Scanty,  serous  secretion. 

Contagious  and  auto-inoculable        Secretion  not  auto-inoculable. 
character  of  the  pus.  j 

Usually  multiple.  i      Usually  single. 

Not  seated  upon  an  indurated  Generally  indurated ;  some- 
base,  times  —  rarely,  however — not. 

Glands  liable  to  become  in-  Glands  indurated,  not  inflamed ; 
flamed ;  when  so,  they  may  sup-  very  rarely  suppurate,  and  then 
purate  and  become  a  chancroid,  from  causes  apart  from  syphilis, 
furnishing  inoculable  pus.  '  Never  furnish  inoculable  pus. 

This  gives  you,  at  a  glance,  the  important  points 
of  difference  between  the  two  ulcers. 

The  site  of  the  initial  lesion  is  a  point  of  much  in- 
terest, and  I  wish  to  recall  to  your  minds  what  I  said 
in  an  earlier  lecture  about  some  forms  of  venereal 
diseases  being  transmitted  without  sexual  contact. 
This  is  the  case  in  syphilis — the  initial  lesion  not  in- 
frequently being  met  with  upon  the  lips,  the  cheek, 
or  upon  the  nipple :  in  the  first  two  cases  from  kiss- 
ing or  from  using  contaminated  utensils,  a  pipe,  a 
spoon,  or  drinking  vessels;  and  in  the  latter  from 
suckling  a  syphilitic  child.  Other  places  are  the  fin- 
gers, the  nose,  the  tongue,  the  throat,  and  the  palpe- 
bral conjunctiva  of  the  eye  ;  in  short,  lay  it  down  as 
an  axiom,  that  7to  portion  of  the  body  is  exempt  from 
being  the  seat  of  the  initial  lesion^  altJiougJi  the  ge7ii- 
tals  are  the  usual  seat,  a  fid  naturally  so  from  being 
more  exposed. 

The  source  of  infection  is  another  point  to  which 


THE  INJTIAL   LESION   OF  SYPHILIS.  37 

I  invite  your  attention.  A  chancroid,  as  I  have  al- 
ready explained  to  you,  comes  from  a  chancroid  or  a 
chancroidal  bubo  ;  but  syphilis  is  caused  in  other 
ways  than  from  inoculation  of  the  secretion  of  an  ini- 
tial lesion.  The  secretion  from  mucous  patches, 
whether  of  skin  or  mucous  membranes,  as  well  as 
the  blood  of  a  syphilitic,  during  the  first  twelve 
months  at  least  of  the  disease,  is  capable  of  infecting 
a  sound  person,  but,  as  I  have  already  told  you,  it  is 
not  auto-inoculable.  The  tears,  saliva,  and  sweat  are 
innocuous,  and  until  within  a  few  years  human  milk 
was  included  in  this  category,  but  some  recent  ex- 
periments have  made  this  doubtful,  although  the  re- 
ported cases  are  by  no  means  co;ivincing.  It  is  the  con- 
tagious property  of  blood  and  mucous  patches  which 
cause  many  of  the  cases  of  initial  lesion  of  the  lips, 
cheeks,  and  nipple  ;  the  patient,  not  being  aware  of  the 
danger,  kisses  healthy  persons  who  perhaps  have  an 
abrasion  of  the  lips,  and  the  disease  is  lighted  up  in  them. 
As  regards  the  nipples,  the  mucous  patches  of  the 
baby's  mouth  perform  the  same  office  for  the  nurse. 

Suppose  the  infection  to  be  derived  in  one  case 
from  the  secretion  of  an  initial  lesion,  in  a  second 
from  that  of  a  mucous  patch,  and  in  a  third  from 
syphilitic  blood  ;  how  does  the  disease  begin  in  these 
cases  ?  Ahuays  by  an  initial  lesion  seated  at  the  point 
where  the  virus  gained  entrance^  never  in  any  otJier 
way.  Syphilis  does  not  first  make  its  appearance  in 
the  form  of  a  so-called  secondary  eruption  without  a 


38  VENEREAL   DISEASEJS. 

preceding  initial  lesion,  although  there  are  some 
cases  where  this  would  seem  to  be  so.  These  cases 
are  when  the  initial  lesion  is  seated  in  some  unusual 
or  not  readily  accessible  place — as,  for  example,  in  the 
urethra  of  the  male,  in  the  cervix  uteri,  upon  the  lips 
or  fingers  of  both  sexes.  When  it  is  seated  in  the 
urethra,  palpation  often  reveals  the  remaining  indu- 
ration, and  sometimes  separation  of  the  labia  ure- 
thrae  reveals  the  syphilitic  erosion  ;  and  a  slight, 
gleet-like  discharge  is  also  present. 

Another  cause  of  confusion,  when  the  patient  has 
not  come  under  observation  until  after  the  outbreak 
of  general  symptoms,  is  that  the  initial  lesion  becomes 
changed"  into  a  mucous  patch — a  symptom  of  the  so- 
called  secondary  stage  ;  but  even  here  the  traces  of 
the  induration  will  put  you  upon  your  guard  as  to  the 
real  nature  of  this  supposed  mucous  patch. 

The  initial  lesion  is  also  subject  to  complications, 
though  to  a  less  extent  than  the  chancroid  ;  the  prin- 
cipal ones  being  phimosis  and  phagedena.  When 
phimosis  attacks  the  initial  lesion  it  is  not  so  likely  to 
produce  such  serious  consequences  as  when  it  occurs 
with  the  chancroid,  owing  to  the  inflammation  being 
much  less,  and  also  to  the  fact  that  the  initial  lesion 
does  not  ulcerate.  The  only  danger  to  be  apprehend- 
ed from  this  complication  is  gangrene,  and  that  may 
be  so  readily  and  easily  obviated  by  an  incision  as 
to  practically  rob  it  of  one-half  its  danger.  You  note 
that  I  said  "  easily   obviated  by  an  incision,"  and  I 


THE  INITIAL   LESION    OF  SYPHILIS.  39 

wish  you  Here  to  remember  what  was  said  in  regard 
to  this  complication  when  speaking  of  the  chancroid. 
Then  I  advised  you  not  to  cut,  unless  obliged  to,  be- 
cause the  edges  of  the  wound  would  become  chan- 
croidal ;  but  in  the  initial  lesion  no  such  danger  is  to 
be  apprehended  ;  the  secretion  of  the  lesion  and  the 
blood  of  the  syphilitic  are  incapable  of  being  auto-in- 
oculated. You  may  therefore  operate,  if  you  see  fit, 
at  once,  so  far  as  contagion  is  concerned,  but  I  should 
advise  waiting  a  little,  for  the  following  reasons  :  first, 
because  no  operation  should  be  done  if  the  same  re- 
sult can  be  attained  in  any  other  way  ;  and,  secondly, 
because  the  induration,  even  if  very  thick  and  mark- 
ed, will  disappear  under  proper  treatment  and  with  it 
the  phimosis.  But  should  gangrene  threaten,  then 
you  not  only  may,  but  should  operate  to  avert  this 
threatened  evil,  and  you  may  practise  the  single  or 
the  double  incision  already  advised  in. Lecture  II. 

Phagedena,  in  syphilis,  is  of  as  grave  import  as  in 
chancroid,  and  comes  from  the  same  cause,  viz.:  con- 
stitutional defects,  due  to  alcoholic  abuse,  or  to  a  mor- 
bid diathesis,  and  it  plays  an  important  part  as  re- 
gards prognosis.  The  ulceration,  instead  of  being 
superficial,  then  becomes  deep  and  wide-spread,  the 
floor  IS  gray  and  pultaceous,  the  secretion  m.ore  abun- 
dant, and  the  induration  may  entirely  melt  away  un- 
der the  phagedenic  action.  Where  the  initial  lesion 
is  phagedenic  the  subsequent  lesions  are  apt  to  take 
on  ulceration,  and  to  pursue  a  rapid  course,  being  re- 


40  VENEREAL   DISEASES. 

bellious   to  treatment,  and  exposing  the   patient  to 
grave  and  serious  consequences. 

Before  going  on  to  speak  of  treatment,  let  me  say 
a  few  words  about  what  is  generally  called  the  ' '  mixed 
sore."  I  wish  the  term  could  be  abandoned,  as  it  is 
confusing  and  does  not  convey  a  correct  idea  of  the 
facts.  It  is  really  a  double  sore  ;  there  is  no  mixture 
whatever  of  nature,  course,  or  virus  ;  it  is  simply  where 
inoculation  of  a  chancroid  and  syphilis  occur  simulta- 
neously in  the  same  person.  The  two  poisons  being  re- 
ceived at  the  same  coitus,  they  operate  differently  as 
regards  the  time  of  their  appearance.  The  chancroid 
appears  first ;  remember,  it  has  no  period  of  incubation, 
and  runs  its  course  and  perhaps  gets  well  before  the  ini- 
tial lesion  comes  upon  the  stage.  At  a  later  period, 
usually  varying  from  ten  to  twenty-one  days  after  the 
infecting  coitus,  the  initial  lesion  appears,  marked  by 
its  peculiar  characteristics.  It  sometimes  happens 
that  the  chancroid  has  not  healed  before  the  first 
symptom  of  syphilis  is  due.  This,  then,  is  what  hap- 
pens :  the  chancroid  is  surrounded  with  a  ring  of  in- 
duration, the  secretion  becomes  less  copious,  the  floor 
fills  up  and  appears  redder  and  healthier,  and  the 
nearest  chain  of  glands  is  indurated  ;  the  chancroid 
has,  in  other  words,  become  changed  into  an  initial 
lesion.  But  through  the  whole  performance  there  is 
no  interchange  of  characteristics,  the  two  lesions  re- 
main entirely  distinct,  and  "  mixed  chancre  "  is,  to  my 
mind,  a  misnomer  ;   I  prefer  to  call  it  a  double  infec- 


THE  INITIAL   LESION   OF  SYPHILIS.  41 

tion,  double  in  the  sense  that  two  kinds  of  virus  have 
been  deposited  in  the  same  spot. 

It  is  in  these  cases  of  double  infection  that  you 
will  be  most  likely  to  meet  with  a  suppurating  bubo, 
the  pus  of  which  is  auto-inoculable,  and  which,  un- 
less you  are  forewarned,  may  lead  you  to  believe 
that  syphilis  is  attended  with  a  suppurating,  auto- 
inoculable  bubo.  The  bubo  is  chancroidal,  similar 
to  what  we  have  already  studied,  has  nothing  to  do 
with  the  syphilis,  although  it  is  contemporaneous 
with  the  initial  lesion,  and  will  require  the  treatment 
appropriate  to  chancroidal  buboes. 

As  regards  treatment  it  is  simple  and,  so  far  as  the 
local  trouble  is  concerned,  effective  in  the  majority 
of  cases.  In  the  first  place,  let  me  beg  of  you  7iever 
to  cauterize  an  initial  lesion  nnless  it  should  be  at- 
tacked by  phagedena.  I  know  it  is  the  rule  to  caute- 
rize every  suspicious-looking  ulcer,  but  in  the  case  of 
the  initial  lesion  it  not  only  does  harm  in  irritating  an 
otherwise  simple  ulceration,  but  it  retards  its  healing. 
Dress  the  lesion  simply  ;  sometimes  a  piece  of  lint 
laid  over  the  ulceration  or  erosion  will  suffice,  but  at 
other  times  a  little  more  active  treatment  may  be 
requisite.  Of  all  dressings  I  much  prefer  the  dry, 
and  of  them  iodoform  heads  the  list,  either  alone  or 
in  combination  with  other  drugs.     Thus — 

3-     Iodoform  pulv. 

Lycopodii  pulv.  p.  ae. 


42  VENEREAL   DISEASES. 

Or— 

;^ .     Pulv.  zinc,  ox 2  parts. 

Pulv.  iodoformi i  part. 

Or— 

!^ .     Pulv.  hydrarg.  chlor.  mit i  part. 

Pulv.  iodoforaii 2  parts. 

Calomel,  without  anything  else,  may  also  be  used 
with  advantage. 

A  mode  much  practised  in  the  German  hospitals  is 
to  apply  a  piece  of  the  Emplastrum  de  Vigo  cum 
mercurio,  the  size  of  the  ulcer,  directly  upon  the  sore, 
and  leave  it  thus  protected  from  the  air,  until  the 
ulcer  heals  up.  The  Emplastrum  hydrargyri,  U.S. P. , 
will  answer  as  well. 

If  you  prefer  to  use  a  wet  dressing,  a  weak  solution 
of  carbolic  acid  is  the  best,  of  which  the  following 
will  serve  as  an  example : 

^, .     Cryst.  ac.  caibol g'*-^ • 

Aquse 3  iv. 

M. 

Apply  on  lint  or  cotton  thrice  daily. 

Constitutional  treatment,  whether  internal  or  ex- 
ternal, is  better  not  employed,  save  in  exceptional 
cases,  until  the  subsequent  (secondary)  symptoms 
appear,  because,  in  many  instances,  it  is  impossible  to 
diagnosticate  the  nature  of  the  lesion  under  observa- 
tion, and  inasmuch   as  mercury,  when  given  during 


THE  INITIAL   LESION  OF  SYPHILIS.  43 

the  existence  of  the  initial  lesion,  has  a  tendency  to 
retard  the  outbreak  of  the  secondary  symptoms,  it 
leaves  the  surgeon  in  doubt  as  to  what  the  disease 
really  is,  and  unable  to  tell  his  patient  what  or  what 
not  to  expect.  Delaying  until  secondary  lesions 
come  on,  or  until  the  period  at  w^iich.  they  should 
appear  has  passed,  does  not  injure  the  patient's  pros- 
pects of  recovery,  and  it  does  give  the  surgeon  the 
opportunity  of  informing  his  patient  as  to  the  nature 
of  his  disease. 

There  are  cases  where  it  is  necessary  to  cure  the 
initial  lesion  rapidly,  as  for  instance  in  married  peo- 
ple, and  to  retard,  and  as  far  as  possible  check  the 
subsequent  manifestations  ;  but  in  such  cases  the  pa- 
tient should  be  told  that  by  so  doing  the  surgeon 
will  be  unable  to  tell  him  or  her  what  subsequent 
symptoms  to  expect,  or  to  count  upon  probable  re- 
covery, even  after  many  months  of  treatment. 

These  exceptions  do  not  then  conflict  with  this  gen- 
eral law,  viz.,  do  not  treat  the  initial  lesion  by  the 
inter 71  al  tise  of  mercnry,  but  aivait  the  development 
of  secondary  symptoms. 

Internal  treatment  by  tonics,  iron,  quinine,  and  the 
like  are  admissible  in  this  stage,  should  the  patient 
be  anaemic,  a  very  frequent  condition  in  syphilis. 


LECTURE  IV. 

SYPHILIDES   OF   THE   SKIN   AND   APPENDAGES. 

In  the  last  lecture  we  passed  in  review  the  initial 
lesion  of  syphilis,  dwelling  upon  its  characteristics  and 
the  main  points  of  difference  which  exist  between  it 
and  the  chancroid.  This  lecture  I  propose  to  devote 
to  considering  the  nature  of  the  subsequent  lesions 
which  occur  in  syphilis,  what  are  commonly  known  as 
the  secondary  and  tertiary  symptoms,  more  particular- 
ly those  which  occur  upon  the  skin,  reserving  the  syph- 
ilides  of  the  mucous  membranes  to  a  subsequent  oc- 
casion. 

In  the  first  place  as  regards  the  nomenclature  :  I 
wish  you  to  remember  that  the  terms  secondary  and 
tertiary  are  ones  of  mere  convenience,  and  must  not 
be  accepted  in  a  purely  chronological  sense.  Many 
of  the  symptoms  which  are  classed  as  tertiary,  may, 
and  do,  appear  in  the  secondary  period,  as,  for  exam- 
ple, the  affections  of  the  nervous  system,  and,  should 
you  be  too  bound  down  to  name  and  rank  all  affec- 
tions of  the  nervous  system  as  necessarily  tertiar}% 
you  will  involve  yourselves  in  much  confusion  and 


SYPHILID ES  OF  SKIN  AND  APPENDAGES.     45 

trouble.  The  true  distinction  I  believe  to  be  this, 
viz.  :  that  during  the  secondary  stage  the  symptoms 
are  more  superficial,  and  more  amenable  to  treatment 
than  they  arc  during  the  tertiary  period,  and  that  the 
exudations  which  occur  during  the  earlier  stage,  are 
absorbed  and  removed  more  speedily  than  those  of 
the  latter.  In  addition  to  this  they  have  not  the  same 
destructive  tendency,  for  we  shall  find  as  we  go  on 
that  the  tertiary  lesions  are  marked  by  deep,  and  ot- 
tentimes  serious,  loss  of  tissue,  while  the  secondary 
lesions  are,  comparatively  speaking,  mild,  and  leave 
behind  no  traces  of  their  presence.  I  therefore  much 
prefer  to  speak  of  these  lesions  as  the  superficial  and 
the  deep  lesions  of  syphilis,  irrespective  of  their  seat, 
whether  on  skin  or  mucous  membrane,  in  the  eye,  ear, 
nervous  system,  or  bone. 

Before  the  symptoms  upon  the  skin  and  mucous 
membranes  appear  there  is  a  period  of  rest  (incuba- 
tion) between  the  occurrence  of  the  initial  lesion  and 
the  advent  of  the  subsequent  manifestations,  during 
which  time  the  initial  lesion  may  have  entirely  healed 
up,  leaving  only  the  induration  of  its  former  site,  and 
an  induration  of  the  nearest  chain  of  glands  as  traces 
of  its  presence.  Even  these  latter  may  be  very  in- 
distinct, rendering  the  connection  between  the  two 
sets  of  symptoms  vague  and  uncertain,  and  the  rela- 
tion each  bears  to  the  other  would  be  overlooked  un- 
less you  were  forewarned.  Note,  then,  that  there  are 
two  periods  of  incubation  in  the  early  stages  of  syphi- 


46  VENEREAL  DISEASES. 

lis,  the  first  being  betiveen  the  infecting  coitus  and  the 
appea7'ance  of  the  initial  lesion,  and  the  second  be- 
tween the  appearance  of  the  initial  lesion  and  the  com- 
ing on  of  the  early  syphilides. 

The  length  of  this  incubative  stage  varies  within 
certain  Hmits,  as  does  the  incubation  of  the  initial 
lesion.  For  all  practical  purposes  you  may  con- 
sider the  maximum  limit  as  about  ninety  days,  or 
three  months,  the  average  being  forty-two  to  forty- 
five  days,  or  between  six  and  seven  weeks.  The 
minimum  limit  you  may  fix  at  twenty-five  days, 
or  between  three  and  four  weeks,  just  about  the 
length  of  the  incubative  period  of  the  initial  le- 
sion. 

Formulate  for  yourselves,  then,  this  rule  :  the  early 
syphilides  have,  like  the  initial  lesion,  a  period  of  in- 
cnbution,  the  average  lejigth  of  which  is  forty -five 
days,  but  zuhich  may  extend  to  ninety^  beyond  zvhich 
time  it  is  rarely  protracted,  sinless  it  has  been  pro- 
longed by  the  internal  treatment  of  the  initial  lesion 
zvith  mercury. 

Before  the  early  syphilides  make  their  appearance 
there  are  certain  vague  and  by  no  means  constant 
symptoms  which  precede  them  by  a  few  days,  and 
which  are  known  under  the  name  of  **  prodromata." 
These  are  fever,  rheumatoid  pains  of  the  muscles, 
aching  of  the  bones,  especially  of  the  superficial  long 
bones,  such  as  the  ulna  and  the  tibia,  and  headache, 
usually  confined  to  one  lateral  half  of  the  head  (hcmi- 


SYPHILID ES  OF  SKIN  AND  APPENDAGES.     47 

crania).  The  peculiar  feature  ot  these  symptoms  is 
that  they  come  on  at  night  when  the  patient  is  in  bed, 
but  not  until  the  heat  of  the  body  has  warmed 
the  bed ;  hence  in  those  patients  whose  occupations 
oblige  them  to  turn  day  into  night,  such  as  bakers, 
the  pains  come  on  in  the  daytime,  when  they  are 
warm  in  bed — so  it  seems  to  be  the  heat  really 
which  brings  out  the  pains  and  not  necessarily  the 
time.  When  the  patients  are  up  and  about,  these 
symptoms  vanish.  During  the  fever  there  may  also 
be  a  slight  rise  in  temperature,  although  this  is  not 
constant. 

After  the  prodromata  have  lasted  for  a  few  days, 
the  syphilides  make  their  appearance  upon  the  skin 
and  mucous  membranes,  and  the  first  of  these  is  the 
erythema  syphiliticitni,  or,  as  it  is  commonly  called, 
"  roseola."  And  here  again  I  wish  to  protest  against 
the  names  which  have  been  commonly  given  to  these 
syphilides  of  the  skin.  They  are,  roseola  for  the 
erythemata,  psoriasis  for  the  scaly  eruptions,  which 
come  upon  the  palms  of  the  hand  and  soles  of  the 
feet,  ecthyma  and  rupia  for  the  pustulo-crustaceous 
manifestations  of  the  later  stages  of  syphilis,  and  are 
borrowed  from  the  slight  resemblance  they  have  to 
the  corresponding  non-venereal  eruptions  which  ap- 
pear on  the  skin.  The  objection  I  make  to  these 
names  is  that  they  are  complicated  and  confusing, 
and  I  much  prefer  the  nomenclature  I  shall  presently 
give  you  as  being  simpler,  and  more  accurately  de- 


>  Syphilides. 


48  VENEREAL  DISEASES. 

scribing  their  pathological  condition.     The  names  I 
propose  for  your  use  are — 

Erythematous, 

Papular, 

Papulosquamous, 

Pustular, 

Pustulocrustaceous, 

Tuberculo-crus:  aceous. 

Ulcerating  ^ 

and  V  Gummata. 

Non-ulcerating  ) 

This  includes  all  the  varieties  of  the  syphilitic  man- 
ifestations of  the  skin,  and  the  advantage  of  their 
names  is  that  it  describes  accurately  the  pathological 
condition  of  the  lesion  and  the  cause  at  the  same  time. 
Thus  a  papulo-squamous  syphilide,  although  a  little 
longer  than  syphilitic  psoriasis,  tells  you  more,  and 
the  same  is  true  of  pustulo-crustaceous  syphilide  as 
against  syphilitic  ecthyma.  I  shall,  therefore,  in  de- 
scribing the  syphilides  of  the  skin,  use  the  above 
nomenclature,  and  the  one  which  heads  the  list  is  the 
erythematous  syphilide. 

Varieties  :   Erythema  maculatum— Erythema 

papulatum. 

Erythema  mactdattnn. 

This  is  the  first  one  of  the  skin  eruptions  to  make 
its  appearance,  coming  on  about  forty-five  days  after 


SYPHILIDES  OF  SKIN  AND  APPENDAGES.     49 

the  initial  lesion,  and  is  characterized  by  rose-colored 
blotches,  not  elevated  above  the  surrounding  skin, 
abundant  over  the  entire  trunk,  arms,  and  legs,  some- 
times invading  the  face,  notably  the  forehead,  and 
occasionally  being  met  with  on  the  inside  of  the 
hands  and  on  the  soles  of  the  feet.  Just  before  the 
rash  fully  declares  itself,  there  is  a  peculiar  mottling 
of  the  skin,  looking  as  though  the  eruption  were  un- 
der the  cuticle  but  had  not  yet  made  its  way  through. 
There  may  be  at  this  time  some  nocULrnal  syphilitic 
fever y  with  a  slight  increase  of  temperature.  One 
other  symptom  I  have  reserved,  as  I  wish  to  dilate 
a  little  at  length  upon  it,  and  that  is,  there  is  no  itch- 
ing. Syphilitic  eruptions  do  not  itch,  although  the 
skin  of  syphilitics  is  often  irritable,  hence,  if  you  in- 
quire of  such  if  there  be  any  itching,  they  will  as 
likely  as  not  reply  in  the  affirmative,  yet  when  you 
come  to  examine  the  skin  there  are  no  marks  of  fin- 
ger nails,  as  are  found  in  phtheiriasis,  eczema,  lichen, 
etc.  Do  not,  therefore,  be  thrown  off  your  guard  by 
any  supposed  itching  of  the  skin  in  syphilis  (of  course 
if  lice  are  present  the  case  is  different,  but  their  pres- 
ence and  subsequent  removal  will  explain  and  cure 
this  symptom),  although  there  may  be,  especially  in 
women,  an  irritability  of  the  derma. 

The    erythematous    syphilide   pursues    its    course 
evenly  and  quietly,  passing  on  from  the  distinct  rose- 
colored  stains  to  a  coppery  hue,  then  to  a  dingy  yel- 
low, and  finally  disappears  entirely  with  a  slight  des- 
3 


so  VENEREAL  DISEASES. 

quamation  of  the  cuticle,  leaving  no  trace  of  its  pres- 
ence. A  few  words  about  the  coppery  hue  of  the 
syphilides.  Its  diagnostic  importance  has  been 
much  exaggerated,  and  you  will,  in  many  non- 
venereal  skin  eruptions,  see  as  much  of  the  copper 
color  as  you  will  in  the  syphilides. 

Erythema  papidaitim. 

This  variety  of  erythema  comes  on  after  the  macu- 
lar kind,  sometimes  even  before  its  entire  disappear- 
ance, and  seems  to  be  the  intermediate  link  between 
the  erythemata  and  the  papulae.  It  is  raised  above 
the  level  of  the  skin,  is  flattened  and  seated  upon  a 
broad  base,  is  of  a  darker  hue  than  its  congener,  the 
erythema  maculatum,  and  always  more  or  less  scaly. 
This  desquamation  in  the  syphilides  is  somewhat 
different  from  what  takes  place  in  the  simple  kinds 
of  eruptions;  it  is  rather  a  peeli7ig  than  an  actual 
scaling.  It  is  less  widely  distributed  than  the  macu- 
lar kind,  being  found  chiefly  on  the  back  of  the  neck, 
on  the  back,  and  on  the  volar  surfaces  of  the  arms 
and  legs ;  it  also  affects  the  palms  of  the  hands  and 
the  soles  of  the  feet  rather  more  than  the  E.  macula- 
tum. Not  infrequently,  as  I  have  already  said,  it  is 
found  conjoined  upon  the  body  with  the  macular 
variety  ;  indeed,  in  certain  parts  of  the  body  where 
heat  and  moisture  are  found,  the  macular  seems 
rapidly  to  pass  into  the  papular  eruption.  This  is 
especially  noticeable   about  the   genitals   of  women 


SYPHILIDES  OF  SKIN  AND  APPENDAGES.      5 1 

where  these  papules  become  quite  luxuriant  in  their 
growth  and  secrete  abundantly  ;  perhaps  you  recall 
several  cases  of  the  kind  which  I  have  already  shown 
you  in  the  wards.  This  variety  paves  the  way  to  the 
next  stage  in  the  disease  where  papules  take  the 
place  of  the  ery  themata. 


Varieties  :  Papula  miliares — Papul.^  lenticu- 

LARES. 

Papulce  miliares. 

The  course  which  the  erythemata  pursues  varies 
somewhat  according  to  the  intensity  and  the  amount 
of  acuteness  of  the  disease.  Sometimes  the  ery- 
thema will  entirely  disappear,  leaving  the  skin  un- 
blemished, and  this  freedom  from  disease  may  last 
for  some  weeks  before  the  next  step  is  reached. 
Here  you  see  then  a  tendency  to  incubation  even 
between  the  various  kinds  of  the  eruption,  but  some- 
times the  attack  is  much  more  rapid  than  this,  and 
before  one  form  of  eruption  has  gone  another  comes 
on,  so  that  upon  the  same  subject  you  will  find 
macules,  papules,  and  even  pustules  scattered  over 
the  body,  constituting  what  is  known  as  '' polymor- 
phismr  Remember  then  that  the  papules  may  not 
appear  until  several  weeks  after  the  disappearance  of 
the  erythemata,  especially  if  a  mercurial  treatment 
has  been  instituted,  or  it  may  come  "  with  a  rush," 


52  VENEREAL  DISEASES. 

so  to  speak,  one  train  of  symptoms  crowding  upon 
the  other,  leaving  no  interval  of  repose  or  apparent 
freedom  from  the  disease.  We  will  suppose  that  the 
macules  have  disappeared  and  that  the  papular  stage 
is  due  ;  what  must  we  look  for  ?  The  nocturnal  pains 
which  had  become  almost  nil  now  returfiy  and  there 
may  be  so?ne  fever,  when  suddenly  over  the  entire 
body,  arms,  legs,  face,  and  scalp,  small  pointed  ele- 
vations of  a  reddish  color  break  out,  which  are  closely 
packed  together,  and  are  sometimes  crowned  at  their 
apices  with  a  small  scale.  These  go  on  for  several 
weeks  getting  more  and  more  purple  in  hue,  the 
papules  become  more  scaly,  less  elevated,  and 
finally  melt  away,  leaving  a  staining,  which  from 
being  at  first  purple  becomes  a  yellowish  brown, 
and  this  in  its  turn  is  absorbed,  leaving  the  skin  free 
from  scar  or  blemish  of  any  kind.  These  papules  are 
small  and  bear  some  resemblance  to  the  simple  acne 
which  invades  the  face  and  shoulders,  save  that  they 
are  much  more  numerous  ;  hence  the  name  some- 
times given  it,  of  acne  syphilitica.  One  peculiarity 
about  this  eruption — indeed,  you  may  say  about  all 
the  s}philitic  eruptions — is  their  tendency  to  assume 
a  circular  form,  grouping  themselves  in  the  shape  of 
a  ring  or  segments  of  a  ring  over  the  body,  and  this 
is  kept  up  even  into  the  late  stages  of  the  disease. 

When  these  papules  are  seated  upon  the  forehead, 
they  assume  somewhat  the  appearance  of  a  ribbon  or 
band  stretched  from  temple  to  temple,  and  among 


SYPHILIDES  OF  SKIN  AND  APPENDAGES.      53 

the  older  syphilographers  received  the  fanciful  name 
of  **  Corona  Veneris,"  a  by  no  means  inapt  title. 
These  papules  extend  into  the  hairy  scalp,  where  from 
irritation  of  the  comb  and  finger-nails  the  apices  be- 
come covered  with  a  bloody  scab,  somewhat  resem- 
bling the  disease  of  the  scalp  called  impetigo  capitis. 
We  shall  see  the  same  thing  occur  in  the  pustular 
stage  of  syphilis,  except  that  there  the  crust  is  larger 
and  thicker. 

Papulce  lenticulares. 

After  the  miliary  papules  have  run  their  course, 
sometimes  even  before,  the  next  variety  of  i  the  same 
eruption,  the  lenticular,  manifests  itself  in  the  shape 
of  broad  flat  papules,  considerably  raised  above  the 
surface  of  the  skin,  of  a  color  similar  to  the  pre- 
ceding, but  covered  with  a  thicker  and  darker 
scale,  which  occasionally  become  transformed  into  a 
very  thin  crust,  due  to  exudation  from  the  papule 
itself.  These  papules  are  not  widely  disseminated 
'over  the  body  as  are  the  erythemat^i  or  the  papulae 
miliares,  but  are  found  in  isolated  groups  upon  the 
palms  of  the  hands  and  soles  of  the  feet,  between  the 
fingers  and  toes,  upon  the  genitals  of  both  sexes,  at 
the  angles  of  the  mouth,  where  they  are  frequently 
continuous  with  mucous  patches  of  the  buccal  cavity, 
at  the  edge  of  the  hairy  scalp,  upon  the  shoulder 
blades,  on  the  buttocks  and  thighs.  When  grouped 
together,  as  they  often  are,  and  covered  with  scales, 


54  VENEREAL   DISEASES. 

they  bear  some  resemblance  to  patches  of  psoriasis 
vulgaris,  but  in  this  latter  disease  the  scales  are  of  a 
more  silvery  white  color,  and  are  smaller  than  is  the 
case  in  syphilis.  When  found  upon  the  genitals  and 
between  the  toes,  the  heat  and  moisture  of  the  parts 
favor  their  growth  and  development;  they  lose  their 
scales,  and  the  secretion  which  exudes  from  them 
covers  their  surfaces  with  a  dirty  white  layer,  which 
can  be  wiped  off,  revealing  a  glazed  red  floor.  These 
are  the  lesions  which  have  been  described  as  mucous 
patcJics  of  the  skin,  but  which  the  Germans  more  ac- 
curately call  the  **  moist  secreting  papule." 

When  seated  at  the  junction  of  mucous  and  cuta- 
neous surfaces  on  the  genitals  the  papule  retains  very 
much  the  same  characteristics  as  the  mucous  patch, 
but  at  the  angles  of  the  mouth  the  skin  lesion  from 
exposure  is  covered  with  a  dry  scale,  sometimes  a 
thin  crust,  while  the  lesion  of  the  mucous  membrane 
is  moist  and  covered  with  a  whitish  pellicle. 

But  it  is  to  their  position  upon  the  palms  and  soles 
that  I  wish  to  invite  your  special  attention.  In  the 
beginning  of  their  growth  the  papules  are  broad, 
flattened,  and  of  a  deep  purple  color,  the  apices  are 
covered  with  scales,  which  are  renewed  as  soon  as 
they  get  rubbed  off.  Later  on  these  papules  coal- 
esce and  form  broad  patches,  which  become  fissured 
and  bleed,  and  the  blood  mingled  with  scales  forms 
a  thin  crust  upon  the  surface  of  the  lesion.  These 
patches  extend  in  size,  become  very  much  thickened, 


SYPHILID ES  OF  SKIN  AND  APPENDAGES.      55 

and  covered  as  they  are  with  scales  and  dried  blood, 
are  often,  with  difficulty,  distinguishable  from  chronic 
eczema  of  the  palms  of  the  hands.  But  I  beg  you  to 
bear  in  mind  that  this  latter  affection  is,  in  my  expe- 
rience, a  rather  uncommon  disease,  whereas  a  papular 
syphiiide  of  the  palms  is  not  infrequent.  Of  course, 
when  you  are  able  to  get  a  history  of  syphilis,  the 
nature  of  the  lesion  is  clear,  but  sometimes  you  may 
get  none,  perhaps  cannot  ask  for  any,  and  in  such 
cases  it  will  stand  you  in  good  stead  to  remember 
that  nine  times  in  ten  such  lesions  of  the  hands  and 
feet  mean  syphilis. 

Formulate,  then,  this  rule  :  Squamous  affections 
of  the  palms  of  the  hands  and  of  the  soles  of  the  feet 
are  nearly  always  syphilis  and  require  anti- syphilitic 
treatment. 

We  are  now  nearing  the  boundary  line  which  is 
supposed  to  separate  the  secondary  and  tertiary  le- 
sions, and  heretofore  we  have  noticed  no  tendency 
to  ulcerative  destruction  ;  all  the  lesions  go  off  and 
leave  no  trace  behind  them.  But  in  the  next  stage 
this  is  changed,  pus  is  formed,  and  pus  means  de- 
struction of  tissue.  The  lesions  which  we  are  now  to 
consider  I  have  divided  into  two  groups,  the  pustu- 
lar and  the  pustulo-crustaceous ,  i.  e. ,  those  which  re- 
main pustular,  not  becoming  covered  with  a  crust, 
but  being  absorbed,  and  those  which  break  down 
and  are  covered  with  a  scab. 


56  VENEREAL  DISEASES. 


PUSTUL.^. 

This  variety  begins  differently  from  any  which  we 
have  heretofore  examined,  having  its  seat  more 
deeply  embedded  in  the  tissues  than  the  papule,  and 
starts  from  the  true  skin  and  not  in  the  epidermis. 
It  is  the  kind  known  in  the  books  as  *'  impetigo 
syphilitica."  Starting  then  from  the  deeper  layers 
of  the  skin,  it  is  felt  beneath  the  surface  as  a  small 
hard  point,  which  rapidly  becomes  elevated  and  is 
crowned  at  its  apex  with  a  pustule.  This  pustule  in- 
creases in  size,  and  may  occupy  the  entire  base  upon 
which  it  is  seated,  said  base  being  surrounded  by  a 
purple  areola,  while  the  pustule  itself  is  yellow. 
This  pustule  is  full,  round,  and  in  the  majority  of 
cases  distended  with  matter,  which,  if  the  pustule  is 
broken,  dries  into  a  small  superficial  crust,  revealing 
on  removal  a  slight  ulceration  beneath.  Moreover, 
this  pustule  is  not  umbilicated,  as  is  the  case  in  vari- 
ola. Provided  the  course  of  the  disease  is  favorable, 
the  pustule  dries  up  and  becomes  covered  with  a  few 
flakes  of  dried  epidermis  ;  these  are  subsequently  cast 
off,  and  a  discoloration  of  the  skin  remains.  After  a 
longer  or  shorter  time  this  staining  fades  away,  and 
unless  the  pustule  has  started  from  deep  down  in  the 
tissues  no  scar  is  left  behind.  If  its  origin  has  been 
deep-seated,  after  the  pigmentation  vanishes,  a  white 
scar  is  visible,  corresponding  to  the  size  of  the  pus- 


SYPHILIDES  OF  SKIN  AND  APPENDAGES.      57 

tule,  and  is  due  to  an  atrophy  of  the  cellular  tissue 
beneath  the  skin.  This  is  not  so  marked  as  it  is  in 
the  crustaceous  syphilides. 

These  pustules  are  widely  scattered  over  the  body, 
the  head,  face,  trunk,  arms,  and  legs  being  invaded, 
resembling,  in  this  respect,  the  erythematous  and 
papular  syphilides.  This  variety  may  be  succeeded 
by  another  crop  of  pustules  of  the  kind  I  have  here 
designated  as  crustaceous,  and  which  are  more  seri- 
ous than  the  ones  we  have  just  studied,  inasmuch  as 
they  are  always  attended  by  ulceration,  sometimes 
quite  extensive,  and  are  not  so  amenable  to  treatment. 

PustulcB  critstacece. 
The  pustulo-crustaceous  syphilides  commence  with 
a  more  pronounced  and  more  diffused  amount  of  ex- 
udation beneath  the  skin  than  do  the  non-ulcerating 
pustules  ;  they  come  rapidly  to  the  surface,  the  pus- 
tule breaks,  and  when  it  does  an  ulceration  more  or 
less  extensive  is  found  beneath.  Sometimes  this  ul- 
ceration does  not  penetrate  deeply  into  the  tissues, 
but  spreads  laterally  over  quite  an  extent  of  surface, 
secretes  abundantly,  and  presents  irregularly  shaped 
borders  (scalloped),  due  to  the  coalition  of  several  in- 
dividual pustules  or  groups  of  pustules.  This  is 
known  in  the  books  as  syphilitic  ecthemr..  At  other 
times  the  pustule  increases  enormously  in  size,  ulcer- 
ates, and  the  ulceration  extends  deeply  into  the  tis- 
sues, making  a  punched-out  cavity,  which  is  covered 
3* 


58  VENEREAL  DISEASES, 

over  by  a  thick  brown  or  black  crust,  due  to  the  ad- 
mixture of  blood  with  the  pus.  This  crust  contin- 
ually increases  in  height  from  accretion,  at  its  base, 
of  fresh  matter  from  destruction  of  tissue,  and  forms 
over  the  ulcer  a  conical  scab,  from  one-half  to  two 
inches  in  height,  which  is  firmly  mortised  into  what 
seems  to  be  sound  skin,  but  which,  on  removal  of  the 
crust,  is  seen  to  *be  undermined  by  the  ulceration. 
This  undermining  of  tissue  is  also  found  in  the  so- 
called  ecthymatous  variety,  but  in  a  much  less  de- 
gree. This  is  the  rupia  of  the  books,  one  of  the 
worst  forms  of  the  syphilides  you  will  be  called 
upon  to  deal  with,  and  which  is  frequently  rebellious 
to  treatment. 

The  seat  of  both  varieties  is  more  limited  than  is 
that  of  the  non-ulcerating  pustules,  and  when  they 
appear  are  more  likely  to  be  discrete.  The  face,  the 
upper  arm,  the  thighs,  and  the  buttocks  are  their  fa- 
vorite situations,  although  they  are  sometimes  found 
upon  the  trunk,  especially  the  back. 

Closely  conjoined  with  the  pustulo-crustaceous 
syphilides  in  nature  and  course  are  the  tuberculo- 
crustaccous  eruptions.  They  affect  the  same  por- 
tions of  the  body  as  the  former,  and  only  differ  in 
their  commencement  in  being  larger  and  harder,  and 
may  be  regarded  as  the  connecting  link  between  the 
pustule  and  the  gumma.  The  ulceration  which  en- 
sues runs  much  the  same  course  as  in  the  so-called 
rupia — is  deep,  destructive,  and  often  rapid,  the  crust 


SYPHILID ES  OF  SKIN  AND  APPENDAGES.      59 

is  thick  and  elevated,  and  in  its  subsequent  course 
is  not  to  be  distinguished  from  its  congeners  of  the 
pustular  variety.  When  I  come  to  speak  to  you 
about  the  syphilitic  affections  of  mucous  membranes, 
I  shall  show  how,  under  certain  conditions,  these  ul- 
cerating syphilides  may  be  mistaken  for  chancroids. 

The  next  and  last  symptom  to  be  spoken  of  is  the 
gumma  (pi.  gummata),  in  which  the  amount  of  infil- 
tration into  the  skin  and  cellular  tissues  is  very  abun- 
dant and  brawny,  and  if  it  breaks  down  gives  rise  to 
a  very  serious  and  nasty-looking  ulceration.  Two 
varieties  of  this  gummous  infiltration  exist,  the  diffuse 
and  the  circumscribed,  and  both  kinds,  if  left  un- 
treated, will  ulcerate.  The  resulting  sore  is  deep, 
has  a  tendency  to  burrow,  has  a  yellowish  floor  cov- 
ered with  the  remains  of  dead  and  dying  tissue,  and 
secretes  abundantly — in  many  of  these  points  resem- 
bling a  chancroid,  but  in  their  nature  they  are  entirely 
dissimilar.  A  chancroid  becomes  worse  under  a 
mercurial  course  ;  it  is  poison  to  it,  while,  in  the  lesion 
under  consideration,  mercury  is  the  only  thing  that 
will  do  it  permanent  good. 

These  gummata  are  found  upon  the  thighs  and 
arms  more  frequently  than  they  are  elsewhere,  and 
are  single  rather  than  multiple,  although  they  may  be 
associated  with  gummata  in  the  viscera  and  in  mucous 
membranes.  When  patients  have  arrived  at  this 
stage  of  visceral  syphilis  a  very  peculiar  condition  of 
the  system  supervenes  :    what   is  known  under  the 


6o  VENEREAL   DISEASES. 

name  of  "  syphilitic  cachexia."  In  this  stage  they 
steadily  but  surely  run  down,  the  functions  are  no 
longer  active,  assimilation  either  of  food  or  medicine 
ceases,  and  death  supervenes  from  exhaustion.  Hap- 
pily such  cases  are  rare,  but  their  occurrence  serves 
to  show  what  syphilis  is  capable  of  doing. 

We  have  now  finished  the  study  of  the  lesions 
known  as  syphilides  of  the  skin,  and  I  have  given  you 
the  salient  points  found  in  them  without  burdening 
your  minds  with  unnecessary  details.  I  have  passed 
over  two  varieties  in  silence  :  the  vesicular  and  the 
bulbous  syphilides,  which  are  described  in  some  trea- 
tises on  venereal  diseases.  I  omit  them  for  two  rea- 
sons— first,  because  I  doubt  their  separate  existence 
(both  of  them  really  belong  to  the  pustular  syphi- 
lides); and  secondly,  if  they  do  exist  they  are  so  very 
rare  as  to  make  them  curiosities  of  syphilis  rather 
than  regular  lesions,  and  my  object  in  these  lectures 
is  to  avoid  undetermined  points  and  to  give  you  only 
what  is  practical  and  certain.  But  before  passing  on 
to  a  consideration  of  the  effects  of  syphilis  upon  the 
appendages  of  the  skin,  I  wish  to  say  a  few  words  as 
to  the  general  course  which  the  cutaneous  syphilides 
pursue. 

In  the  first  place,  after  the  initial  lesion  has  passed 
away,  there  may  be  a  period  of  apparent  immunity 
from  the  disease  before  the  syphilides  appear ;  this  I 
have  already  told  you  is  the  period  of  incubation  be- 
tween the  so-called   primary  and  secondary  stages. 


SYPHILID ES  OF  SKIN  AND  APPENDAGES.     6 1 

The  erythemata  appear  and  disappear,  leaving  an- 
other intermission  between  the  erythemata  and  the 
papulae,  and  this  period  varies  from  two  weeks  to  one 
or  two  months,  according  to  the  activity  and  efficacy 
of  treatment.  After  the  subsidence  of  the  papules, 
another  period  of  repose  of  several  weeks  may  occur 
before  anything  further  appears,  when  some  variety 
of  the  papular  syphilides  will  recur,  or,  if  the  disease 
is  progressing,  pustules  will  show  themselves.  So  it 
goes  on,  each  stage  advancing  progressively  from 
superficial  to  deep  lesions  —  from  those  symptoms 
which  are  mild  and  which  are  readily  absorbed,  to 
those  which  are  ulcerative,  destructive,  and  which 
are  not  absorbed. 

But,  in  place  of  advancing,  we  will  suppose  the 
disease  yields  to  treatment ;  what  do  we  see  then  ? 
The  erythema  vanishes,  and  the  patient,  though  kept 
under  observation  for  some  time,  displays  nothing 
more  ;  or,  at  the  end  of  several  months,  he  may  show 
a  slight  recurrence  of  the  erythema,  or  perhaps  a  few 
scattered  papules.  Treatment  is  vigorously  pushed, 
the  papules  disappear,  and  the  patient  hears  nothing 
more  from  his  syphilis.  He  is,  to  all  intents  and  pur- 
poses, well.  But  there  is  one  point  I  wish  to  lay 
stress  upon  :  syphilis  never  ricns  a  hap  hazard  course^ 
it  never  begins  with  deep-seated  lesions  first,  to  show 
later  on  superficial  ones,  but  it  pursues,  if  a  serious 
case,  a  pretty  steady  course  from  bad  to  worse  ;  if, 
on  the  contrary,  it  be  a  light  case,  occasional  relapses 


62 


VENEREAL  DISEASES. 


of  the  same  kind  of  eruption  may  occur,  but  it  never 
skips  about.  I  shall  i:evert  to  this  point  again  when 
I  come  to  speak  of  the  prognosis. 

As  regards  the  course  these  lesions  pursue,  you 
may  lay  down  this  broad  general  principle  :  the  su- 
perficial lesions  disappear  pretty  quickly,  the  deep- 
seated  ones  quite  slowly.  In  order  that  you  may  com- 
prehend this  readily,  I  append  here  a  table  giving  ap- 
proximatively  the  time  after  the  appearance  of  the 
initial  lesion  at  which  the  various  syphilides  are  due, 
and  their  duration. 


NAME. 

DUE, 

DURATION. 

Erythema. . .  . 

Papules 

Pustules 

6-12  weeks 

3-6  weeks. 

4-8  weeks. 

2-4  months  and  more. 

■^-2  years  and  more. 

2-6  months .. , 

6-15  months. 
1-5  years  and 

Gummata.  . .  . 

more 

As  appendages  of  the  skin,  the  hair  and  the  nails 
invite  our  attention,  and  of  the  former  there  are  two 
varieties  of  syphilitic  disease  known  as  alopecia,  one 
of  which  occurs  in  the  early,  and  the  other  in  the  late 
stage.  The  early  alopecia  is  the  more  general  of  the 
two,  not  being  confined  to  the  hairy  scalp,  its  usual 
seat,  but  attacking  the  hair  of  the  face,  and  even  of 
the  entire  body.  I  have  seen  one  case  where  the  pa- 
tient lost  all  the  hair  of  his  head,  face,  and  body.  This 
seems  to  be  due  to  changes  going  on  in  the  hair  bulbs 
themselves,  and  not  to  any  changes  in  the  follicles,  so 


SYPHILIDES  OF  SKIN  AND  APPENDAGES.      63 

that  the  hair  grows  again  as  luxuriantly  as  before. 
This  is  not  the  case  in  the  late  stage,  when  the  lost 
hair  is  not  generally  replaced,  and  this  is  due  to  dis- 
ease of  the  follicles  themselves,  as  well  as  to  their  de- 
struction from  deep  ulcerations  of  the  scalp,  face,  etc. 

The  early  alopecia  is  coincident  with  the  erythema 
and  papules,  the  late  with  the  pustular  and  tuberculo- 
crustaceous  eruptions. 

The  affections  of  the  nails  belong  to  the  late  stage 
of  syphilis,  and  are  usually  concomitant  with  the 
pustular  lesions.  During  the  existence  of  the  papulo- 
squamous syphilides,  however,  the  nails  of  fingers 
and  toes  are  sometimes  affected  ;  they  crack,  the  edges 
become  ragged  and  uneven,  and  at  times  scaling  of 
the  surfaces  takes  place.  But  later  on  in  the  disease, 
pustules  occur  in  the  matrix  of  the  nail,  causing  de- 
tachment, and  the  nail  drops  off.  After  this  happens 
the  ulceration  of  the  matrix  may  continue,  destroying 
it  and  with  it  all  hope  of  a  renewal  of  the  nail.  If 
the  ulceration  is  checked  before  this  stage  is  reached, 
the  nail  may  be  reproduced  ;  but  its  growth  is  very 
slow,  the  new  nail  is  brittle,  uneven,  and  ragged,  and 
is  seldom  of  much  use. 


LECTURE  V. 

SYPHILIDES    OF    MUCOUS    MEMBRANES — SYPHILITIC 

ADENITIS. 

Following  naturally  upon  the  syphilides  of  the  skin 
come  the  syphilides  of  mucous  membranes,  and  these 
are  among  the  most  common  of  ail  the  affections  of 
the  earlier  stages  of  the  disease,  as  well  as  the  most 
obstinate  to  treat.  They  recur  again  and  again,  of- 
ten being  the  only  symptom  of  syphilis  which  remains 
after  the  first  outbreak  has  passed  away,  and  are  fre- 
quently a  source  of  more  annoyance  to  the  patient 
than  any  of  the  manifestations  upon  the  skin,  except 
it  be  those  of  the  face. 

Like  the  syphilides  of  the  cuticle,  the  syphilides  of 
the  mucous  membranes  are  divisible  into  the  superfi- 
cial and  deep  kinds,  the  former  of  which  are  not  in 
themselves  serious  ;  the  latter  of  extreme  importance, 
from  the  consequences  which  they  entail  from  de- 
struction of  tissue. 

Coincident  with  the  outbreak  of  the  erythema  ma- 
culatum,  the  patient  will  complain  of  a  feeling  of 
soreness  of  the  throat  and  dryness  of  the  fauces.  In- 
spection reveals  the  entire  mucous  membrane  of  a 


SYPHILIDES  OF  MUCOUS  MEMBRANES,         65 

congested  red  color,  or,  as  occasionally  happens,  hav- 
ing spaces  of  sound  mucous  membrane  between  the 
congested  spots,  and  resembling,  in  many  respects, 
the  eruption  upon  the  skin. 

Sometimes  this  erythema  is  continuous  upon  the 
mucous  membrane  of  the  tongue  and  the  entire  buc- 
cal cavity,  and  so  general  is  it  that  it  may  be  mis- 
taken for  a  scarlatinal  sore  throat,  particularly  if  the 
syphilitic  fever  has  been  at  all  sharp.  But  a  little 
attention  to  the  other  symptoms  will  save  the  physi- 
cian from  such  a  mistake,  and  the  treatment  will  defi- 
nitely settle  the  doubt.  The  sides  of  the  tongue  are 
dotted  with  small  punctate  spots,  giving  it  some- 
what the  look  of  a  ripe  raspberry,  and  has  quite  a 
peculiar  appearance.  With  all  this  congestion  there 
are  very  few  physical  symptoms;  the  voice  is  not  ma- 
terially changed,  the  breathing  is  not  impeded,  nor 
is  deglutition  difficult.  The  tonsils  are  sometimes 
enlarged,  and  can  be  felt  externally  as  well  as  seen 
internally,  and  the  glands  of  the  posterior  and  ante- 
rior cervical  regions  are  indurated  aud  slightly  en- 
larged. In  addition  to  these  sets  of  glands,  the  fol- 
lowing may  also  be  implicated  ;  the  anterior  and 
posterior  auricular,  the  submental  and  the  submax- 
illary. 

This  erythema  of  the  mucous  membranes  disappears 
in  the  same  time  and  manner  as  the  erythema  of  the 
skin,  only  as  the  parts  are  protected  from  the  air  no 
desquamation  occurs.     The   congestion    tones  down 


66  VENEREAL  DISEASES, 

from  purple  to  red,  the  red  to  the  normal  pink  hue 
of  mucous  membranes,  and  on  vestige  of  the  disease 
is  left. 

Here,  also,  as  with  the  syphilides  of  the  skin,  we 
may  have  a  period  of  rest  and  freedom  from  symp- 
toms, but  of  all  the  manifestations  of  the  earlier  stage 
of  syphilis,  this  is  the  most  persistent,  and  the  patient 
will  hardly  get  rid  of  one  crop  of  eruptions  before 
another  crop  is  ushered  in,  and  that,  too,  while  treat- 
ment is  going  on.  Sometimes  this  may  be  a  relapse 
of  the  erythema  faucium,  or  it  may  be  a  form  which 
I  am  now  about  to  describe. 

The  patient  consults  the  surgeon  for  a  soreness  of 
the  throat  resulting,  as  is  frequently  stated,  from  cold 
conjoined  with  ''  fever-sores  "  upon  the  tongue  and 
mucous  portions  of  the  lips  and  cheeks.  An  exam- 
ination shows  the  mucous  membrane  of  these  parts 
slightly  thickened,  as  though  from  infiltration  of  the 
parts,  and  on  the  surface  are  seated  opaline,  glisten- 
ing patches  of  a  white  color,  devoid  of  any  true  ulcer- 
ation, and  usually  sensitive  to  the  action  of  hot  and 
cold  drinks,  pungent  condiments,  etc.  This  tender- 
ness is  specially  noticeable  when  the  lesions  are  seated 
upon  the  tongue  or  lips.  Associated  with  these  mu- 
cous patches  there  may  be  found  upon  the  body  a 
papular  or  papulo-pustular  eruption,  but  very  often 
there  is  nothing  at  all  except  the  lesions  of  the  mu- 
cous membranes  upon  which  to  found  a  diagnosis. 
I  know  of  few  points  in  syphilis  more  puzzling  to  de- 


SYPHILID ES  OF  MUCOUS  MEMBRANES.        6/ 

cide  upon  than  these  same  mucous  patches,  particu- 
larly when  patients  insist  upon  their  being  associa^ed 
with  a  disordered  condition  of  the  stomach,  when  for 
want  of  certainty  as  regards  history  and  antecedents 
the  surgeon  falls  into  the  error  of  considering  them 
as  simple  ''aphthae." 

The  white  covering  of  the  mucous  patches  is  closely 
adherent  to  the  tissues  below,  and  it  cannot  be  de- 
tached without  causing  some  slight  hemorrhage  ;  in- 
deed, in  some  cases,  this  white  film  is  really  below 
the  surface,  and  is  an  actual  infiltration  into  the 
submucous  tissues  with  external  ulceration. 

This  form  of  mucous  patch  is  extremely  obstinate, 
and  recurs  repeatedly  upon  the  same  spot,  or  upon 
adjacent  parts  of  the  membrane.  Gradually,  how- 
ever, under  active  and  persistent  treatment  they  dis- 
appear, it  may  be  for  good,  or  else  they  reappear  in 
another  form  corresponding  to  a  more  advanced  stage 
of  the  disease. 

This  variety  is  specially  to  be  found  in  the  throat, 
its  favorite  habitat  being  the  tonsils  and  the  posterior 
arches  of  the  palate.  Occasionally  it  is  found  upon 
the  dorsum  and  sides  of  the  tongue,  less  frequently 
upon  the  buccal  mucous  tissue.  Its  first  appearance 
is  a  slight  elevation  of  the  membrane  from  infiltration 
into  the  submucous  tissue,  but  this  does  not  last ;  the 
elevation  breaks  down  and  is  converted  into  an  ulcer- 
ation varying  in  depth  according  to  the  infiltration. 

The  floor  is  uneven  and  gray  in  appearance  and 


68  VENEREAL  DISEASES. 

the  secretion  is  not  very  abundant.  But  little  in- 
convenience results  to  the  patient  from  their  pres- 
ence, as  the  parts  become  callous  from  the  infiltration 
and  thickening  of  the  tissues,  and  the  ulcers  are  not 
sensitive  to  heat  and  cold  as  they  were  in  the  earlier 
stage.  These  ulcers  have  a  tendency  to  extend  slow- 
ly, it  is  true,  but  still  deeply,  and  when  they  are 
seated  upon  the  tonsils  or  behind  the  posterior  arches 
of  the  palate,  they  become  of  quite  large  size.  It  is 
at  this  stage  that  a  change  in  the  character  of  the 
voice  takes  place,  and  the  usual  clear  tone  is  ex- 
changed for  a  hoarse  whisper  or  an  uneven  strident 
sound.  An  examination  by  the  laryngoscope  shows 
ulceration  of  the  mucous  membrane  of  the  larynx  and 
of  the  false  vocal  cords  with  oedema.  On  attempted 
phonation  it  is  seen  the  true  cords  do  not  come  even- 
ly together,  hence  the  calibre  of  the  voice  is  materi- 
ally altered. 

Succeeding  this  stage,  sometimes  merging  into  it, 
is  the  true  ulcerative  syphilide  of  mucous  membranes, 
due  to  the  breaking  down  of  the  gumma,  which  forms 
in  the  submucous  cellular  tissue.  The  first  thing  to 
attract  attention  is  a  diffuse  brawny  swelling  of  the 
soft  parts,  which  progresses  rapidly,  breaks  down, 
and  when  it  occurs  in  those  portions  of  the  body  that 
act  as  septa  between  cavities,  it  produces  important 
and  irremediable  destruction.  The  action  is  rapid  in 
these  cases,  a  few  days  being  oftentimes  sufficient  to 
produce  extensive  disfigurement.      I  shall  return  to 


SYPHILID ES  OF  MUCOUS  MEMBRANES.         69 

this  topic  when  I  come  to  speak  upon  the  syphiHs  of 
special  organs. 

In  the  last  lecture  I  spoke  to  you  of  cases  In  which 
ulcerating  gummata  of  mucous  membranes  might  be 
mistaken  for  chancroids.  A  patient  who  has  been  the 
subject  of  an  old  and  long-standing  syphilis  will  pre- 
sent himself  to  the  surgeon  with  a  circumscribed  hard 
tubercle  seated  upon  the  mucous  membrane  of  the 
penis,  either  in  the  fossa  glandis,  on  the  reflex  layer 
of  the  prepuce,  or  at  the  junction  of  the  frsenum  with 
the  fossa.  This  tubercle  is  perfectly  painless,  unat- 
tended with  any  inflammation,  and  apparently  indo- 
lent in  character.  It  will  suddenly  break  down,  be- 
come converted  into  a  deep,  piinched-out  ulcer,  cor- 
responding in  extent  with  the  original  tubercle,  pre- 
senting a  yellow,  uneven  floor,  devoid  of  induration, 
and  secreting  a  thin,  viscid  fluid,  which,  from  irrita- 
tion, will  become  purulent.  If  this  lesion  be  seen  for 
the  first  time  in  the  ulcerated  stage,  it  may  readily  be 
mistaken  for  a  chancroid,  especially  as  it  evinces  de- 
structive tendencies,  for  it  may  eat  away  the  fraenum, 
burrow  into  the  urethra,  and  extend  far  beyond  the 
limits  of  the  gumma  which  gave  it  birth.  These  are 
puzzling  cases  to  decide  upon  ;  the  history  will  some- 
times help  you  to  a  diagnosis,  but  of  all  things  the 
treatment  will  be  the  experimentum  crucis. 

The  ordinary  remedies  for  chancroid  are  useless ; 
cautery  and  local  dressings  do  not  produce  the  re- 
sults they  should,  and  you  begin  to  despair.     Change 


70  VENEREAL   DISEASES. 

your  tactics,  and  without  giving  up  topical  applica- 
tions, except  the  cautery,  put  your  patient  upon,  a 
mixed  treatment  (mercury  conjoined  with  the  iodide 
of  potassium),  and  the  result  will,  I  know,  gratify  you  ; 
the  lesion  will  get  well. 

Conjoined  with  these  symptoms  of  the  skin  and  mu- 
cous membranes,  during  the  earlier  stages  of  syphilis, 
are  others  fully  as  important  for  you  to  know  about 
and  remember.  I  refer  to  the  enlargement  of  the 
glands  over  the  entire  body,  and  which  goes  under 
the  name  of  adenitis  universalis.  You  remember 
when  we  were  studying  the  initial  lesion,  I  called  your 
attention  to  the  induration  of  the  chain  of  glands  near- 
est to  the  lesion,  and  told  you  at  the  time  how  im- 
portant it  was.  As  the  period  arrives  for  the  out- 
break of  the  subsequent  lesions,  the  glands  all*  over 
the  body,  the  anterior  and  posterior  cervical,  the  sub- 
maxillary and  submental,  the  anterior  and  posterior 
auricular,  the  occipital,  the  epitrochlear,  and  the  in- 
guinal glands  are  found  enlarged  and  indurated.  This 
manifestation  is  coincident  with  the  erythema  cutis 
et  faucium,  and  with  the  alopecia  which  marks  the 
early  stages  of  syphilis.  Under  treatment  these  in- 
durated glands  slowly  subside,  but  their  subsidence  is 
very  gradual,  and,  if  the  result  has  been  very  good,  no 
trace  is  left  behind  ;  but  usually  a  slight  hardness  re- 
mains even  after  the  patient  has  entirely  recovered 
from  his  illness,  sufficient  to  show  the  practised  finger 
that  trouble  has  existed. 


SYPHILITIC  ADENITIS.  71 

This  induration  differs  very  widely  from  the  braw- 
niness  and  hardness  which  obtains  with  some  chan- 
croids. The  condition  of  the  glands  in  chancroid 
you  are  already  familiar  with,  but  the  adenitis  in  this 
stage  of  syphilis  you  are  not  conversant  with.  In 
the  first  place,  the  glands  are  painless  ;  secondly,  they 
are  unattended  with  acute  inflammation ;  and  thirdly, 
they  do  not  suppurate.  They  appear  as  round  ker- 
nels, from  the  size  of  a  small  buckshot  to  that  of  a 
large  pea,  lying  just  beneath  the  skin,  and  upon 
handling  they  roll  about  perfectly  freely  under  the 
tissues.  This  constitutes  the  form  of  infiltration  of 
glands  which  occurs  during  the  early  stages  of  syphi- 
lis ;  in  the  later  stages  of  the  disease  another  variety 
occurs,  which  is  entirely  different  in  its  course  and 
nature.  This  is  called  the  gummous  infiltration  of 
glands,  and  resembles  in  a  slight  degree  a  chan- 
croidal bubo,  just  as  the  broken-down  gummata  of 
the  penis  will  simulate  a  chancroid.  It  begins  as 
an  infiltration,  not  only  of  the  gland  itself,  but  of 
the  circumglandular  tissue,  which  becomes  tense 
and  brawny,  and  breaks  down  unless  its  course  be 
checked  by  proper  treatment.  There  is  one  very 
notable  point  in  this  breaking  down  :  the  skin 
covering  the  swelling  opens  in  several  places,  and 
what  comes  from  the  enlargement  is  not  pus,  but 
a  thin,  sticky,  colorless  fluid,  not  unlike  thin  gum. 
This  exudation  is  not  abundant  at  any  one  given 
time,    but    comes    away    continuously,    and    its    dis- 


72  VENEREAL   DISEASES. 

charge  does  not  materially  diminish   the  size  of  the 
swelling. 

This  completes  the  circle  of  symptoms  on  the  skin 
and  mucous  membranes  likely  to  be  met  with  in  the 
average  cases  of  syphilis  which  will  fall  to  your  lot, 
as  practising  physicians,  to  treat.  But  there  are 
other  lesions  to  which  I  wish  to  call  your  attention, 
fully  as  important  as  any  you  have  heretofore  stud- 
ied, the  consideration  of  which  I  shall  reserve  for  a 
separate  lecture. 


LECTURE   VI. 

SYPHILIS   OF   SPECIAL   ORGANS. 

The  lesions  we  are  to  consider  to-day  are  those 
which  affect  the  special  senses  of  sight,  hearing,  smell, 
and  generation  ;  and  as  most  of  them  occur  in  the 
late  and  more  dangerous  stages  of  syphilis,  a  correct 
knowledge  of  their  natural  history  and  course  is  im- 
portant. 

Commencing  with  the  eyelids,  we  find  that  the  skin 
and  mucous  membranes  of  these  organs  are  some- 
times the  seat,  during  the  early  stage  in  syphilis,  of 
the  initial  lesion  and  of  mucous  patches  ;  but  as 
these  symptoms  do  not  differ  in  their  general  char- 
acter from  those  found  elsewhere  upon  the  body, 
they  need  not  detain  us.  During  the  later  stages, 
the  lids  may  also  be  attacked  by  pustules  or  gum- 
mata,  which  pursue  the  same  course  that  similar  le- 
sions do  elsewhere  ;  and  the  description  which  I  have 
given  in  the  two  previous  lectures  will  answer  for 
these  lesions  of  the  lids. 

When  the  initial  lesion  or  mucous  patches  are 
seated  upon  the  palpebral  conjunctiva,  some  inflam- 
4 


74  VENEREAL   DISEASES. 

mation  of  this  tissue  may  ensue  ;  but  it  is  usually  very 
slight  and  limited  in  extent. 

One  of  the  most  serious  syphilitic  lesions  of  the  eye 
is  what  is  known  as  iritis,  or  an  inflammation  of  the 
iris  ;  and  this  is  doubly  dangerous  because,  from  its 
close  relation  w^ith  the  ocular  vascular  tunic — the  cho- 
roid— the  disease  is  liable  to  invade  the  deeper  tissues 
and  result  in  serious  consequences  to  vision. 

This  symptom  usually  comes  on  about  the  sixth 
month  of  the  duration  of  the  syphilis — sometimes, 
however,  as  early  as  the  third  ;  and  is  associated  wdth 
a  syphilide  of  the  skin  and  mucous  membranes.  It 
commences  with  what  the  patient  calls  a  "weakness 
of  the  eye,"  which,  upon  examination,  is  found  to  be 
very  much  congested,  and  this  congestion  is  present, 
not  only  in  the  vessels  of  the  conjunctiva,  but  of  the 
sclerotic  also.  It  is  more  marked  close  to  the  border 
of  the  iris,  near  the  cornea,  and  is  attended  with 
lachrymation  and  photophobia.  Upon  close  inspec- 
tion, the  iris  of  the  affected  eye  is  seen  to  be  of  a  dull 
hazy  color,  to  have  lost  its  lustre,  and  it  looks  as 
though  it  were  infiltrated  with  fluid.  The  pupil  is  small 
and  contracted;  and  if  a  few  drops  of  atropine  be  drop- 
ped into  the  eye,  the  opening  will  be  found  irregular 
in  shape,  and  the  pupillary  margin  of  the  iris  bound 
down  to  the  anterior  capsule  of  the  crystalline  lens. 

Note,  then,  these  points  in  syphilitic  iritis  : 

\st.  Congestion  of  the  vessels  of  the  conjunctiva  and 
sclera. 


SYPHILIS   OF  SPECIAL    ORGANS.  7S 

2d.  Lachrymation. 

2,d.  l^JiotopJiobia ;  and 

^tJi.  Adlierence  of  the  pupillary  niai'gin  of  the  iris 
to  the  anterior  capsule  of  the  lens. 

In  addition  to  these  symptoms,  the  patient  com- 
plains of  a  severe  supraorbital  pain,  which,  although 
present  during  the  day,  is  more  intense  at  night,  de- 
priving the  patient  of  rest  and  sleep. 

It  seldom  happens  that  both  eyes  are  attacked  si- 
multaneously ;  the  usual  course  is  for  one  eye  to  be  af- 
fected first ;  as  the  disease  subsides  in  that,  the  second 
one  succumbs,  and  upon  its  recovery  the  first  one  is 
a  second  time  attacked — making  what  is  known  as  a 
"  see-saw  iritis." 

This  is  the  variety  which  generally  occurs  in  the 
early  stage  of  syphilis ;  but  later  on,  another  kind  ap- 
pears, which  is  still  more  serious.  The  congestion, 
lachrymation,  photophobia,  and  supra-orbital  pain 
are  again  present  in  a  more  intensified  form  ;  the  in- 
filtration is  more  marked  ;  and  at  the  pupillary  margin 
of  the  iris,  apparently  springing  from  the  uvea  iridis, 
an  irregularly  shaped  nodule  is  seen  which  protrudes 
into  the  anterior  chamber,  sometimes  completely 
blocking  up  the  pupil.  This  nodule  may  break  into 
the  anterior  chamber,  and  it  then  discharges  a  pe- 
culiar-looking flocculent  fluid,  which  is  not  pus,  but 
gummy  matter.  This  form  of  gummous  iritis  is  often 
conjoined  with  a  pustular  eruption  upon  the  skin,  or 
with  gummata  of  som.e  portion  of  the  body. 


^6  VENEREAL  DISEASES. 

Under  proper  care  and  treatment,  the  inflamma- 
tion and  congestion  subside,  the  iris  assumes  its  nor- 
mal color,  and  if  the  adhesions  have  not  been  very 
firm,  the  pupil  regains  its  normal  contour ;  but  too 
frequently  the  adhesions  are  permanent,  and  the  pu- 
pil, particularly  when  dilated  by  atropine,  shows  an 
irregular  border  This  may  not,  however,  be  a  seri- 
ous matter,  nor  does  it  necessarily  affect  the  vision. 

In  the  next  stage,  however,  it  is  different.  As  the 
disease  progresses,  the  deeper  tissues  are  affected, 
and  the  patient  complains  of  dimness  of  vision, 
and  deep-seated  pain  in  the  eyes.  Examination 
shows  the  normal  range  of  vision  diminished,  and 
the  ophthalmoscope  reveals  infiltration  of  the  choroid, 
haziness  of  the  choroidal  and  retinal  vessels,  with  pig- 
mentary deposits  in  the  choroid,  which  are  later  on 
succeeded  by  atrophy,  leaving  the  sclerotic  visible 
beneath. 

As  might  be  expected,  diminution  of  the  range  of 
vision  follows  ;  although  in  such  cases  you  will  be  sur- 
prised to  find  how  extensive  are  the  ravages  of  the 
disease,  compared  with  the  amount  of  loss  of  sight. 

Besides  these  affections  of  the  eyeball  proper,  the 
carunculae  lachrymales  and  the  lachrymal  gland  may 
be  the  seat  of  gummata.  This  is  attended  by  swell- 
ing of  the  parts,  which  may,  under  treatment,  dis- 
appear, or  it  may  break  down  and  leave  an  ulcera- 
tion similar  to  other  ulcerating  gummata  of  the  skin. 

The  sypJiilitic  affections  of  the  ear  are  not  so  well 


SYPHILIS   OF  SPECIAL    ORGANS.  77 

understood  as  are  those  of  other  parts  of  the  body. 
The  auricle  and  external  auditory  canal  may  be  the 
seat  of  mucous  patches,  and  this  variety  of  lesion 
belongs,  of  course,  to  an  early  stage.  In  addition, 
the  middle  ear  may  also  be  affected  in  the  early  as 
well  as  late  stage,  and  this  is  due  to  a  probable  infil- 
tration of  the  mucous  membrane  of  the  middle  ear, 
as  well  as  to  an  extension  of  the  disease  from  the 
throat  along  the  Eustachian  tubes.  The  symptoms 
complained  of  are  a  feeling  of  tension  in  the  ear; 
sometimes  tinnitus  aurium,  although  this  is  not  con- 
stant ;  and  a  diminished  power  of  hearing.  These 
are  frequently  associated  with  nocturnal  hemicrania, 
and  the  early  syphilides  of  the  skin  and  mucous 
membranes.  The  speculum  may  show  no  trouble  of 
the  tympanum,  or  at  the  most  a  soggy  condition  of 
this  membrane,  with  a  slight  sinking  of  the  drum-head. 
This  early  lesion  is  not  usually  serious,  as  the  symp- 
toms pass  off  without  affecting  audition  to  any 
marked  degree. 

But, when  syphilis  invades  the  deep  portions  of  the 
ear — the  labyrinth  and  cochlea — then  you  may  expect 
serious  trouble,  and  the  patient  can  consider  himself 
lucky  if  he  retains  even  a  portion  of  his  hearing.  In 
such  cases  the  symptoms  are  vague  and  ill-defined, 
being  limited  to  pain  in  the  head,  which  is  not  spe- 
cially nocturnal  in  character,  and  occasionally  tinnitus 
aurium.  These  continue  for  a  longer  or  shorter  time, 
when  the  patient  suddenly  wakes  up  some  morning 


7^  VENEREAL   DISEASES. 

to  find  himself  perfectly  deaf.  This  peculiarity  of 
suddenness  in  the  attack  is  one  worth  your  study,  for 
you  will  find,  when  you  come  to  examine  other  cases 
of  nervous  syphilis,  that  the  same  trait  is  present. 
The  deafness  is  complete;  the  watch  and  tuning-fork, 
when  pressed  against  the  ear,  convey  no  sound,  and 
very  often  the  same  is  true  when  these  instruments 
are  pressed  against  the  bones  of  the  skull  or  the  teeth. 
I  need  hardly  tell  you  in  such  cases  the  prognosis  is 
not  favorable.  The  cranial  pain  is  frequently  severe, 
and  is  not  confined  to  any  one  portion  of  the  head; 
sometimes  being  occipital,  sometimes  frontal,  and  at 
other  times  it  is  vertical  or  basilar.  The  tinnitus  is 
the  most  distressing  phenomenon  in  these  cases,  and 
is  extremely  rebellious  to  treatment,  lasting  even 
after  a  portion  of  the  hearing  power  has  been  re- 
stored. 

The  nose  and  air-passages,  in  common  with  the 
rest  of  the  body,  are  liable  to  invasion  from  this 
infernal  disease,  which  spares  no  tissue  of  the  human 
frame,  but  preys  on  all  alike.  In  the  early  stage  of 
syphilis  the  nasal  mucous  membrane  becomes  con- 
gested, and  is  the  seat  of  mucous  patches  both  in  its 
anterior  and  posterior  portions.  These  manifesta- 
tions yield  readily  to  treatment,  and  produce  only 
slight  discomfort ;  but  as  the  disease  progresses  the 
parts  are  attacked  by  ulceration,  with  or  without 
necrosis  of  the  nasal  and  palatine  bones,  which  give 
rise   to   a   very    fetid,  abundant   discharge.     This    is 


SYPHILIS   OF  SPECIAL    ORGANS.  79 

known  as  ozcena  syphilitica — a  form  of  ulceration 
so  disgusing  and  offensive,  as  to  render  the  subject 
of  it  a  burden  to  himself  and  a  curse  to  those  who  are 
brought  in  contact  with  him.  If  conjoined  with  necro- 
sis of  the  nasal  bones,  the  latter  are  stripped  of  their 
periosteum  and  crumble  away,  causing  collapse  of 
the  bridge  and  sides  of  the  nose,  materially  altering 
the  appearance  of  the  face.  This  stage  of  the  disease 
is  frequently  associated  Avith  gummata  elsewhere, 
either  of  the  skin  or  mucous  membranes. 

The  pJiarynx ,  the  arches  of  the  palate,  the  velum 
palatiy  and  the  viucons  incinbrane  of  the  hard  palate ^ 
are,  during  the  early  period  of  syphilis,  the  seat  of 
mucous  patches,  as  well  as  of  an  erythema  coincident 
with  a  similar  affection  of  the  skin.  Besides  these 
symptoms,  later  on  in  the  disease,  ulcerations,  at  first 
superficial,  afterwards  deep,  occur,  which  are  serious 
according  to  their  extent  and  depth ;  but  the  most  im- 
portant lesion  which  can  attack  these  regions  is  a  gum- 
mous  infiltration.  This  is  grave  in  a  twofold  sense  ; 
first,  from  the  impediment  to  respiration  which  the 
swelling  gives  rise  to,  and,  secondly,  from  the  after- 
effects which  follow  cicatrization  of  the  ulcer  The 
first  sign  of  this  trouble  is  a  feeling  of  fulness  in  the 
throat,  with  some  embarrassment  in  breathing,  due  to 
the  sometimes  enormous  swelling  of  the  tissues  of  the 
part.  This  may  be  uni-  or  bilateral  ;  when  the  lat- 
ter, the  impediment  to  respiration  is  very  marked, 
and  may  necessitate  a  resort  to  tracheotomy,  to  re- 


8o  VENEREAL  DISEASES. 

lieve  the  urgent  want  of  breath.  This  swelling  goes 
on,  unless  checked  by  treatment,  to  ulceration;  and 
the  resulting  sore  is  deep,  with  undermined  edges, 
and  a  copious  discharge  of  gummous  matter  and  pus. 
If  the  velum  palati  be  the  seat  of  the  lesion,  perfora- 
tion and  absolute  destruction  of  this  septum  may 
result,  throwing  the  oral  and  posterior  nasal  cavities 
into  one.  When  ulceration  of  the  pharynx  is  present 
at  the  same  time,  the  cicatrization  which  ensues  pro- 
duces a  partial  stenosis  of  the  upper  portion  of  the 
throat.  One  result  sometimes  occurs,  of  which  I  have 
shown  you  two  examples,  and  it  is  this  :  when  the 
soft  palate  is  only  partially  destroyed,  what  remains 
becomes  adherent  to  the  posterior  pharyngeal  wall, 
producing  occlusion  of  the  entrance  to  the  posterior 
nares,  which  would  be  complete  but  for  cribriform 
openings  in  the  artificial  septum,  through  which  nasal 
respiration  is  imperfectly  carried  on.  If  the  perfora- 
tion of  the  velum  is  limited  in  extent,  under  proper 
treatment  the  opening  may  contract  to  a  size  only  suf- 
ficient to  admit  a  very  fine  probe  ;  but  my  experience 
has  taught  me  that  very  rarely  indeed  does  the  open- 
ing entirely  close  up.  However,  under  favorable 
circumstances,  the  hole  left  behind  is  so  small  as  to 
give  rise  to  no  trouble,  nor  to  allow  regurgitation  of 
solids  and  liquids,  such  as  obtains  while  the  opening  is 
larcre. 

When  the   trachea    and  vocal   cords  are   affected, 
the  symptoms  which  follow  are  grave  and  alarming ; 


SYPHILIS   OF  SPECIAL    ORGANS,  8l 

phonation  above  a  hoarse  whisper  is  prevented  ;  the 
tracheal  rings  are  often  necrosed  and  thrown  ofif ;  and 
death  from  suffocation  may  result  from  oedema  and 
ulceration  of  the  glottis. 

The  cesopJiagiLS  is  also  invaded,  usually  in  connec- 
tion with  syphilis  of  the  larynx  and  trachea,  either 
from  an  extension  of  the  ulceration,  or  else  from  gum- 
mous  infiltration  of  the  tube  itself  The  stricture  of 
the  oesophagus,  which  results  after  cicatrization  of 
the  syphilitic  ulceration,  is  a  very  grave  complication, 
and  frequently  leads  to  a  fatal  termination  from  ex- 
haustion, due  to  inanition,  as  solid  food  cannot  be 
taken  in  sufficient  quantity  to  support  life. 

The  tongue y  as  we  have  already  seen,  is  the  seat  of 
mucous  patches  during  the  early  stage  of  syphilis, 
and  these  symptoms  are  often  quite  obstinate,  recur- 
ring again  and  again  when  all  other  manifestations 
have  apparently  vanished.  From  being  slight  and 
superficial,  the  mucous  patches  may,  during  the  prog- 
ress of  the  disease,  become  painful  and  ulcerated, 
due  in  part  to  the  disease  and  in  part  to  friction 
against  the  teeth.  In  the  later  stages  of  syphilis,  the 
tongue  may  be  attacked  with  a  gummous  infiltra- 
tion, which  may  be  diffuse  or  circumscribed.  In  the 
former  variety,  the  entire  substance  of  this  organ  be- 
comes enormously  swollen  and  thickened  ;  the  surface 
is  glazed,  and  presents  deep  and  ulcerated  fissures  ; 
mastication  is  interfered  with,  and  speech  rendered 
indistinct.  If  the  gummata  are  of  the  circumscribed 
4* 


82  VENEREAL  DISEASES. 

form,  one  or  more  nodules,  hard  and  cartilaginous  to 
the  touch,  are  felt  deeply  imbedded  in  the  tissue  of 
the  organ.  These  nodules  are  painless,  and  do  not 
occasion  the  patient  as  much  inconvenience  as  when 
the  lesion  is  diffuse.  Both  types  may  pursue  two 
courses  :  resolution  or  ulceration.  If  the  first,  the 
thickening  and  ulceration  gradually  subside,  the 
tongue  regains  its  former  pliancy,  mastication  and 
speech  are  recovered,  and  the  organ  shows  no  trace 
of  its  former  trouble.  When  ulceration  occurs,  the 
discharge  is  apt  to  be  abundant  and  ill-smelling ;  the 
ulcer  deep  and  excavated,  surrounded  with  a  thick 
margin  of  brawny  infiltration  ;  mastication  and  speech 
imperfect,  while  the  movements  of  the  tongue  are 
materially  hindered.  This  ulceration  sometimes  lasts 
for  months,  causes  great  destruction  of  the  organ, 
and  when  it  finally  heals  up,  leaves  a  puckered,  de- 
pressed cicatrix,  which  may  deprive  the  tongue  of  its 
accustomed  mobility. 

Passing  to  the  generative  orga7is,  we  find  that  the 
testicles  are  not  infrequently  attacked  by  syphilis  in 
both  the  early  and  late  stages.  In  the  early  period, 
the  epididymis  of  one  or  both  testes  is  hard,  thick- 
ened, and  distended  to  a  sometimes  enormous  size. 
This  enlargement  is  not  painful,  and  only  attracts  at- 
tention from  its  weight  and  from  the  dragging  sensa- 
tion it  produces  upon  the  spermatic  cord,  causing  a 
feeling  of  weakness  in  the  back.  This  form  of  epi- 
didymitis   almost    always    disappears    under   proper 


SYPHILIS  OF  SPECIAL    ORGANS.  83 

treatment,  and  does  not  interfere  with  the  functions 
of  the  part. 

This  is  not  the  case  in  the  advanced  stage  ;  here 
a  true  orchitis  is  found  involving  the  entire  organ. 
The  first  thing  to  attract  the  patient's  attention  is  a, 
sensation  of  weight  in  the  part,  accompanied  by  a 
dragging  upon  the  spermatic  cord,  and  a  pain  in  the 
small  of  the  back.  Upon  examination,  the  entire  tes- 
tis is  found  very  much  enlarged,  hard  as  a  stone,  and 
|)resenting  upon  its  surface  raised  prx)jections  or 
knobs.  There  is  no  redness,  and,  curious  to  tell,  no 
pain ;  the  organ  can  be  very  freely  handled  without 
exciting  any  uneasiness.  This  peculiarity  is  also 
present  in  syphilitic  epididymitis,  and  in  this  respect 
it  differs  very  much  from  the  gonorrhoeal  form  of  this 
disease,  as  I  shall  show  you  by  and  by.  The  shape 
is  piriform,  with  the  small  end  pointing  towards  the 
abdominal  ring.  If  the  disease  pursues  a  favorable 
course,  the  hardness  and  infiltration  subside,  and  the 
organ  may  return  to  its  former  size  and  usefulness  ; 
but  too  often  atrophy  results,  and  the  testis  all  but 
disappears,  sometimes  being  no  larger  than  a  good- 
sized  horse-bean.  Of  course,  when  this  happens,  it 
is  neither  ornamental  nor  useful. 

The  other  course  which  the  disease  may  pursue 
is  ulceration.  One  or  more  of  the  projections  soften, 
break  down,  and  discharge  a  mixture  of  pus  and  the 
gummous  material  with  which  you  are  already  fami- 
liar.    The  ulcer  differs  in  no  respect  from   broken- 


84  VENEREAL  DISEASES. 

down  gummata  elsewhere  ;  is  chronic,  sometimes  last- 
ing for  months  before  it  finally  heals  up  ;  and  when  it 
does,  leaves  behind  it  a  deep,  depressed  scar,  sur- 
rounded by  atrophied  tissue,  which  is  not  so  exten- 
sive as  where  the  infiltration  has  been  more  general. 

Gummous  infiltration  may  also  occur  in  Xh^  ovaries; 
and  the  only  symptom  present  is  swelling,  usually 
painless,  in  the  ovarian  region,  conjoined  perhaps 
with  some  symptom  of  syphilis  elsewhere. 

The  cervix  ttteri  is  not  infrequently  the  seat  of  the 
initial  lesion  and  of  mucous  patches,  and  these  symp- 
toms we  have  already  studied  in  a  previous  lecture. 
But  there  is  one  point  in  this  connection  to  which  I 
invite  attention.  Both  these  lesions  may  be  seated 
within  the  cervix,  between  the  os  internum  and  exter- 
num, showing  nothing  externally  ;  a  slight  discharge 
is  present,  but  no  more  than  is  common  to  nine 
women  in  ten.  Connection  with  women  thus  affect- 
ed gives  rise,  in  the  male,  to  an  attack  of  syphilis, 
and,  unless  care  is  taken  in  forming  the  diagnosis, 
may  occasion  the  error  of  regarding  the  syphilis  of  the 
man  as  arising  from  a  gonorrhoea  or  leucorrhoea  in 
the  female. 

This  would  be  an  error  ;  the  disease  is  contracted 
from  the  secretion  of  an  initial  lesion  or  of  a  mucous 
patch  ;  indeed,  accept  this  axiom  :  syphilis  comes  only 
from  sypJiiliSy  and  not  from  clap  or  a  chancroid.  In 
the  advanced  stage  of  syphilis  the  neck  and  the  body 
of  the  uterus  are  attacked  by  gummata,  which  pre- 


SYPHILIS   OF  SPECIAL    ORGANS.  85 

sent  themselves  in  the  shape  of  diffused  or  circum- 
scribed thickening  of  the  organ,  which  may  follow 
the  usual  course  of  these  lesions  ;  viz.,  absorption,  or, 
as  sometimes  happens  in  the  cervix,  deep  and  obsti- 
nate ulceration,  resembling,  in  many  respects,  an  ex- 
tensive chancroid  of  the  part.  We  also  find  the  same 
in  the  male,  seated  upon  the  penis,  to  which  I  have 
already  alluded  in  a  previous  lecture.  This  gumma, 
besides  occurring  upon  the  mucous  membrane  of  the 
male  genital  organ,  is  sometimes  found  at  the  junction 
of  the  penis  with  the  scrotum — the  peno-scrotal  angle 
— as  a  hard,  diffused,  brawny  swelling,  unattended  by 
pain  or  redness  ;  this  opens  externally  or  internally, 
and  according  as  it  does  one  or  the  other,  gives  rise 
to  certain  symptoms.  If  the  opening  is  external,  the 
resulting  ulcer  is  similar  to  the  ulcerating  gummata 
of  other  parts  ;  and  heals  up,  after  a  longer  or  shorter 
time,  under  appropriate  treatment.  If,  on  the  other 
hand,  the  urethra  is  perforated,  the  gumma  dis- 
charges itself  through  this  canal,  and  gives  rise  to  the 
question  of  gonorrhoea  with  a  peri-urethral  abscess. 
In  the  majority  of  cases  you  will  save  yourselves  from 
falling  into  the  error  of  regarding  this  lesion  as  a  clap, 
by  an  observance  of  the  following  facts  :  in  gonor- 
rhoea the  discharge  precedes  the  swelling,  which  is 
red  dind  paijifiil ;  in  syphilis,  on  the  other  hand,  the 
d\sc\i3.rgQ  follows  the  appearance  of  the  enlargement, 
never  precedes  it^  and  the  swelling  is  neither  red  nor 
pai?tfnL 


86  VENEREAL  DISEASES. 

Another  form  of  gumma  of  the  male  genital  oc- 
curs, to  wit :  an  infiltration  into  the  corpus  spongio- 
sum or  into  the  corpora  cavernosa.  This  usually 
comes  on  in  the  circumscribed  form,  and  is  apparent 
as  a  hard  nodule  without  redness  or  pain,  deeply 
imbedded  in  the  tissue  of  the  part,  or  it  may  occa- 
sionally present  an  annular  form  round  the  entire 
organ.  It  generally  passes  off  under  treatment,  but 
during  its  continuance  it  gives  rise  to  much  incon- 
venience and  to  most  curious  distortion  of  the  part. 
If  only  partial,  it  curves  the  penis  during  erection  to 
one  side  or  the  other,  according  to  the  location  of  the 
gumma,  resembling  the  symptom  known  in  gonor- 
rhoea as  chordee,  and  it  interferes  with  sexual  inter- 
course ;  but  if  it  assume  the  annular  form,  a  most  re- 
markable condition  of  affairs  arises.  During  erection, 
the  penis,  from  the  crura  to  the  seat  of  the  lesion, 
is  turgid,  and  assumes  its  usual  appearance  ;  beyond 
that,  it  is  flaccid  and  hangs  at  right  angles  to  the  rest 
of  the  organ,  looking  like  a  flail.  Of  course,  for 
sexual  purposes  it  is  entirely  useless,  and  but  for  the 
glory  of  the  thing,  the  poor  patient  might  as  well 
have  no  penis  at  all. 

The  alimentary  canal  and  the  viscera  do  not  escape 
any  more  than  do  other  portions  of  the  body.  Dur- 
ing the  existence  of  the  erythema,  a  form  of  icterus 
has  been  described  as  due  to  syphilis,  which  yields  to 
mercury,  but  it  is  not  until  the  later  phases  of  the 
disease  that  these  organs  are  attacked  by  gummata, 


SYPHILIS  OF  SPECIAL   ORGANS.  8/ 

usually  of  the  circumscribed  variety.  These  lesions 
have  been  found  in  the  liver,  lungs,  heart,  kidneys, 
and  intestinal  tract ;  but  the  most  interesting  of  all 
the  syphilitic  manifestations  of  these  parts  is  the 
gumma  of  the  rectum.  This  begins  in  the  muscular 
and  mucous  coats  of  the  rectum,  and  by  its  size  may 
decidedly  diminish  the  calibre  of  the  tube.  The 
neoplasm  ulcerates,  producing  great  pain,  attended 
with  a  discharge  of  purulent  and  gummous  material — 
tenesmus,  diarrhoea,  and  bloody  stools.  Upon  heal- 
ing, it  leaves  behind  it  a  stricture  of  the  rectum,  which 
is  more  or  less  tight,  according  to  the  depth  and  extent 
of  the  ulceration,  and  is  usually  attended  with  obsti- 
nate constipation  from  the  mechanical  obstruction  to 
defecation.  This  stricture  is  extremely  obstinate  and 
rebelUous  to  treatment,  owing  to  its  continual  irrita- 
tion by  faecal  matter,  and  necessitates  a  resort  to  the 
use  of  rectal  bougies  to  keep  the  passage  dilated, 
and  even  surgical  interference,  such  as  a  division  of 
stricture,  or  even  in  extreme  cases  to  colotomy,  to 
prevent  the  rectum  from  being  occluded  and  the 
patient's  life  jeopardized. 

This  lesion  of  syphilis  also  is  of  interest  in  its  bear- 
ing upon  the  chancroid.  You  remember,  perhaps, 
that  in  the  lecture  upon  chancroid,  I  spoke  of  the 
stricture  of  the  rectum  resulting  from  anal  chancroids 
in  the  female.  The  after-effects  differ  in  no  whit 
from  the  same  disease  due  to  syphilis,  and  may  also 
require  subsequent  surgical  treatment  for  its  relief. 


LECTURE  VII. 

SYPHILIS   OF  THE   NERVOUS  SYSTEM   AND   OF   BONE. 

Thus  far  we  have  studied  the  syphiHtic  lesions 
which  occur  in  and  upon  the  body,  with  the  excep- 
tion of  those  which  affect  the  nervous  and  osseous 
systems,  and  these  we  shall  study  in  to-day's  lecture. 

It  is  generally  believed  that  nervous  symptoms  be- 
long exclusively  to  the  late  or  so-called  tertiary  form 
of  syphilis,  but  this  is  a  mistake  ;  lesions  of  the  ner- 
vous system  are  found  during  the  early  period,  being 
sometimes  coincident  with  as  early  a  manifestation 
as  erythema,  but  they  differ  from  late  nerve-syphilis 
in  being  evanescent,  more  amenable  to  treatment, 
and  in  not  leaving  any  permanent  impairment  of  the 
health  behind. 

One  of  the  most  common  symptoms  of  the  early 
stage  is  the  hemicrania  or  headache  confined  to  one 
lateral  half  of  the  head,  and  to  which,  when  speaking 
of  the  syphilides  of  the  skin,  I  called  your  attention. 
This  headache  has  one  peculiarity,  especially  well 
marked  in  the  early  period  of  syphilis ;  it  only 
appears  at  night ;  during  the  daytime  the  patient  is 
free  from  it,  but  on  the  approach  of  night   it  com- 


SYPHILIS  OF  NERVOUS  SYSTEM  AND  BONE.      89 

mences  gradually  at  first,  increasing  in  intensity, 
when  the  patient  goes  to  bed,  and  remaining  until 
morning,  when  it  disappears.  It  usually  affects  one 
lateral  half  of  the  head,  although  it  may  shift  its  po- 
sition to  the  frontal  and  occipital  portions  ;  but  this 
is  not  common.  As  the  syphilis  advances,  this  noc- 
turnal character  changes ;  it  no  longer  disappears 
entirely  throughout  the  day,  although  it  is  less  severe 
in  the  forenoon.  Some  time  in  the  afternoon  it  begins 
to  increase,  and  at  night  becomes  so  intense  as  to 
deprive  the  patient  of  rest  and  sleep.  The  more 
severe  and  advanced  the  type  of  the  syphilis  is,  the 
earlier  in  the  afternoon  does  this  pain  commence. 

Associated  with  this  hemicrania  are  epileptiform 
seizures  of  a  light  and  transient  character,  which,  so 
far  as  the  patients  are  concerned,  pass  unnoticed,  for 
the  simple  reason  that  they  know  nothing  about 
them.  Sometimes  an  attack  occurs  in  public,  when 
of  course  it  becomes  known  ;  but  at  other  times  the 
only  things  to  excite  suspicion  toward  such  a  mani- 
festation are  a  bitten  tongue  or  lips,  or  else  a  bruised 
forehead.  I  recall  one  case  of  a  young  interne  of 
this  hospital  (Charity,  B.  I.),  who  contracted  syphilis 
from  a  wound  on  the  finger  becoming  inoculated,  and 
who  had  these  epileptiform  convulsions  during  the 
existence  of  his  erythema.  He  had  repeated  attacks, 
and  in  many  of  them  was  seen  by  his  room-mate  and 
by  other  internes  of  the  hospital.  My  then  partner, 
the  late  Dr.  Bumstead,  and  myself  were  visiting  in 


90  VENEREAL   DISEASES, 

the  wards,  and  the  case  came  under  our  care.  The 
attacks  were  of  short  duration,  but  well  marked,  the 
jaws  were  firmly  set,  there  was  no  biting  of  the 
tongue,  and  but  slight  foaming  at  the  mouth  ;  the 
body  was  first  rigid,  then  violently  convulsed  for  a 
minute  or  more,  and  all  was  over.  The  patient  re- 
mained dazed  for  a  few  minutes  after,  would  then 
pick  himself  up  from  where  he  happened  to  be  lying, 
and  finish  what  he  was  doing  when  the  attack  came 
on.  The  most  curious  part  of  the  attack  was,  that 
the  being  on  the  floor  or  bed  never  struck  him  as 
strange,  and  he  seemed  to  be  absolutely  ignorant  of 
his  attack.  He  entirely  recovered  under  proper 
treatment. 

As  the  syphilis  advances,  these  attacks  become 
more  frequent  and  severe,  and,  unless  checked  by 
treatment,  affect  the  patient's  mind,  leading  to  an  at- 
tack of  downright  mania,  or,  what  is  more  commonly 
the  case,  to  melancholia  and  idiocy.  But  one  point 
is  deserving  of  notice  —  the  rapid  and  beneficial 
effect  which  accrues  in  cases  which  at  first  look 
almost  hopeless,  under  a  proper  and  thorough  treat- 
ment. 

Associated  with  these  cases  of  syphilitic  epilepsy, 
although  not  necessarily  so,  are  paraplegia  and  hemi- 
plegia, attended  with  certain  symptoms  which  serve 
to  distinguish  them  from  similar  affections  not  due  to 
syphilis.  First  and  foremost  of  these,  stands  the  sud- 
denness with  which  the  attack  comes  on  ;  the  patient, 


SYPHILIS  OF  NER  VOUS  SYSTEM  AND  BONE,     91 

to  use  a  slang  phrase,  is  "  bowled  over  "  without  pre- 
monition. Occasionally  the  patient  will  confess  to 
having  suffered  for  a  short  time  before  the  attack  with 
severe  cranial  pain,  but  just  as  often  as  not  there  are 
no  antecedent  symptoms  ;  the  patient  becomes  sud- 
denly paralyzed.  The  second  noteworthy  point  is,  that 
very  rarely  indeed  is  there  any  loss  of  consciousness  ; 
the  patient  retains  his  senses  perfectly,  has  neither 
stertor  nor  coma  ;  he  simply  finds  he  cannot  move 
certain  portions  of  his  body.  If  he  is  attacked  with 
hemiplegia,  one  lateral  half  of  his  body  is  useless — if 
paraplegia,  the  lower  half;  and  this  latter  form  is  con- 
nected with  obstinate  constipation  and  with  retention 
of  urine,  from  the  inability  of  the  rectum  and  bladder 
to  empty  themselves  of  their  contents.  Paraplegia 
denotes  some  affection  of  the  spinal  cord,  low  down, 
as  a  rule,  and  due  to  compression  either  from  the 
pressure  of  a  gumma  \\\  the  periosteum  of  the  verte- 
brae, or  in  the  sheath  of  the  cord  itself;  while  hemi- 
plegia is  caused  by  some  brain  lesion. 

Age  plays  a  part  also  in  making  up  your  diagno- 
sis ;  and  you  will  remember  that  such  lesions  as  we 
are  now  considering,  occurring  in  an  adult  say  be- 
tween the  ages  of  twenty  and  forty-five,  of  course 
excluding  accidents,  should  always  excite  a  suspi- 
cion of  syphilis  ;  for,  apart  from  injuries  and  the  pox,  , 
these  diseases  are  rare  between  the  ages  I  have  given 
you. 

Let  me  supply  you  with  a  short  table  of  the   dif- 


92  VENEREAL  DISEASES, 

ferential  signs   between  syphilitic  and  non-syphilitic 
paralysis : 


SYPHILITIC    PARALYSIS. 

Sudden,  unattended  by  premoni- 
tory symptoms. 

Consciousness  not  lost. 
,  Breathing  calm,  no  stertor. 

Pulse  regular  and  natural. 

Most  common  between  the  ages 
of  twenty  to  forty-five. 


NON-SYPHILITIC    PARALYSIS. 

Gradual,  and  attended  by  piodro- 
m.ata,  except  in  apoplexy,  when  the 

Patient  becomes  unconscious. 

Breathing  stertorous. 

Pulse  full,  bounding,  and  irregu- 
lar. 

Usual  in  advanced  age. 


This  tabular  form  will,  I  hope,  serve  to  fix  these 
points  in  your  mind. 

Syphilis  of  all  diseases  seems  fond  of  playing  cu- 
rious pranks,  and  the  nervous  system  affords  it  ample 
opportunities.  Besides  the  varieties  of  paralysis 
which  we  have  just  gone  over,  there  are  localized 
forms  that  attack  certain  muscles  or  sets  of  muscles. 
The  most  common  of  these  is  paralysis  of  the  mus- 
cles supplied  by  the  third  pair  of  nerves,  the  mo- 
tores  oculorum  communes.  In  this  affection  the  eye- 
ball is  partially  or  completely  covered  by  the  lid, 
which  cannot  be  raised,  and  the  eyeball  is  incapable 
of  any  movements  except  those  afforded  by  the  ex- 
ternal rectus  and  the  superior  oblique  muscles,  which 
,  you  know  are  supplied  by  the  fourth  and  sixth  pair 
of  nerves.  This  produces  disturbance  of  sight,  with 
diplopia  or  double  vision,  from  inability  to  focus  the 
two  eyes  simultaneously  upon  the  same  object.     It 


SYPHILIS  OF  NERVOUS  SYSTEM  AND  BONE,     93 

also  affects  the  iris,  producing  mydriasis  or  dilatation 
of  the  pupil,  which  is  sometimes  extreme. 

Next  in  frequency  come  the  affections  of  the  fifth 
and  seventh  pairs,  and  here  we  find  a  complete  distor- 
tion of  the  muscles  of  the  face  supplied  by  this  nerve  ; 
the  face  is  pulled  over  to  the  non-paralyzed  side,  be- 
cause there  are  no  antagonistic  muscles  in  action  to 
keep  the  features  straight.  The  tongue,  when  pro- 
truded, is  dragged  over  in  the  same  manner.  The 
patient  cannot  inflate  his  cheeks,  nor  can  he  masticate 
his  food,  as  the  buccinator  and  masseter  muscles  are 
both  incapacitated  ;  his  food  collects  during  eating  be- 
tween his  cheeks  and  jaws,  and  cannot  be  dislodged 
save  with  his  fingers,  and  the  saliva  dribbles  out  of 
the  corner  of  his  mouth.  He  presents,  in  short,  a  ri- 
diculous and  at  the  same  time  a  pitiable  appearance. 
Besides  this  he  cannot  close  the  eyelid  of  the  affect- 
ed side,  and  as  for  winking  with  it,  that  is  out  of  the 
question  ;  the  ala  nasi  of  that  side  does  not  expand 
in  respiration  ;  he  cannot  wrinkle  the  skin  of  his  fore- 
head, nor  can  he  frown  but  with  one-half  of  his  face, 
and  he  may  also  be  made  deaf  on  the  diseased  side. 
Yet  with  all  this  trouble,  if  the  fifth  is  not  attacked, 
there  is  no  loss  of  sensation,  for  the  seventh,  as 
you  know,  is  the  motor,  while  the  fffth  is  the  sen- 
sory nerve  of  the  face.  Whether  all  these  symp- 
toms or  only  a  portion  of  them  occur,  depends  upon 
the  site  of  the  lesion  ;  if  it  is  anterior  to  the  emer- 
gence of  the  nerve  through  the  stylo-mastoid  fora- 


94  VENEREAL  DISEASES. 

men,  all  are  present  ;  if  posterior,  then  only  those 
muscles  supplied  by  the  diseased  portions  of  the 
nerve  are  affected. 

If  the  fourth  pair  is  attacked,  then  the  obliquus 
superior  is  the  only  muscle  at  fault,  and  the  patient 
cannot  turn  the  eyeball  upwards  and  outwards,  and 
if  the  sixth  pair  is  injured  the  eye  cannot  be  everted. 

It  is  so  rare  to  find  these  forms  of  localized  paraly- 
sis apart  from  syphilis,  that  I  do  not  believe  you  will 
ever  be  far  wrong  in  ascribing  such  lesions  to  this  dis- 
ease ;  and  in  cases  where  no  history  can  be  obtained, 
the  importance  of  a  knowledge  of  this  fact  will  be  at 
once  apparent  to  you. 

Let  me,  then,  formulate  this  into  an  axiom  for  you  : 

Paralysis  of  single  imiscles,  or  sets  of  muscles^  are 
nine  times  in  ten  syphilitic. 

These  affections  of  the  nerves  are  nearly  always 
unilateral,  and  I  do  not  know  that  they  occur  more 
frequently  upon  one  side  than  the  other. 

Among  the  spinal  nerves,  the  one  most  commonly 
attacked  is  the  great  sciatic,  which  springs  from  the 
sacral  plexus.  The  principal  symptom  present  is  pain 
along  the  course  of  the  nerve,  and  this  pain  is  not 
acute,  but  dull  and  persistent,  and  is  liable  to  exacer- 
bations at  night.  None  of  the  ordinary  remedies  used 
for  sciatica  do  more  than  mitigate  the  severity  of  the 
pain  ;  but  if  the  surgeon  gets  upon  the  right  track 
and  prescribes  the  iodide  of  potassium  either  alone, 
or,  better  still,  combined  with  mercury,  the  result  is 


SYPHILIS  OF  NERVOUS  SYSTEM  AND  BONE.     95 

oftentimes    as   rapid    as    it   is    gratifying ;    the    pain 
vanishes  Hke  magic. 

The  lesion  which  occurs  in  these  nervous  syphihdes 
is  twofold  ;  either  a  deposit  of  gummous  material 
within  the  nerve-sheath  itself,  or  else  pressure  upon 
the  nerve  during  its  passage  through  some  bony 
canal  or  foramen  by  gummata  of  the  bone.  The 
prognosis  depends  much  upon  the  duration  of  the 
disease;  if  the  syphilis  be  young — i.  e.y  in  its  early 
stage — it  is  favorable  ;  if  the  contrary,  the  prognosis 
is  doubtful,  although  even  here  hope  should  not  be 
abandoned  ;  but  if  atrophy  of  the  nerve  has  resulted 
from  the  pressure  of  the  gumma,  then  good-by  to 
all  chance  of  recovery. 

.  As  regards  the  bones,  the  lesions  here  are  divisible, 
into  those  which  occur  during  the  early  and  those 
which  occur  during  the  late  stages.  To  the  former 
belong  the  osteocopic  pains,  which  produce  no  or- 
ganic changes  in  the  bones  themselves  nor  in  their 
investing  sheath  the  periosteum — which  are  nocturnal 
in  their  character,  and  are  at  the  worst  merely  annoy- 
ing. As  the  syphilis  progresses,  these  pains  lose  a 
great  deal  of  their  nocturnal  character;  they  are  more 
persistent,  but  still,  with  all  this,  they  are  not  danger- 
ous. These  pains  are  usually  confined  to  the  shafts 
of  the  long  bones,  particularly  those  which  are  just 
beneath  the  skin,  such  as  the  tibia  and  the  ulna; 
although  they  sometimes  affect  the  flat  bones — as,  for 
example,  the  cranial. 


96  VENEREAL  DISEASES. 

It  is  when  the  gummous  stage  arrives,  that  trouble 
of  a  serious  nature  arises.  The  first  stage  is  where 
intense  locaHzed  pain  occurs  in  some  bone  either  flat 
or  long — it  makes  no  difference — which  is  speedily 
followed  by  a  swelling  at  this  spot,  oftentimes  exquis- 
itely tender,  but  usually  without  any  redness  of  the 
part.  This  swelling,  if  checked  at  the  outset,  disap- 
pears slowly,  nearly  always  leaving  some  elevation  and 
thickening  of  the  periosteum  behind  it.  If  left  to 
itself,  or  uncontrolled  by  the  treatment,  the  swelling 
increases  in  size  and  extent,  gradually  softens  and 
opens  in  one  or  more  places  to  give  exit  to  pus  and 
the  gummous  material  which  is  common  to  all  the 
lesions  of  the  late  stage.  If  this  opening  be  probed, 
dead  bone  is  almost  always  found  at  the  bottom,  and 
this  bone  conveys  to  the  touch  an  irregularity  on  the 
surface  as  though  it  were  worm-eaten.  And  here 
let  me  impress  upon  your  minds  one  very  important 
maxim  :  NEVER,  7iever  tiiider  any  circumstances ,  opeji 
a  gnmni02LS  enlargement  of  bone  or  gland,  no  matter 
hoiv  soft  it  gets.  I  have  seen  gummous  infiltrations 
of  this  kind  become  absorbed  even  when  the  skin 
covering  them  was  as  thin  as  fine  tissue-paper,  and 
they  looked  as  though  they  must  open.  I  say  to  you 
again,  never  open  a  gumma,  for  by  so  doing  you  de- 
prive yourself  of  the  only  chance  of  preventing 
necrosis  of  the  bone  ;  and  if  this  must  supervene,  do 
not  give  it  a  helping  hand  by  stupid  interference  on 
your  part. 


SYPHILIS  OF  NERVOUS  SYSTEM  AND  BONE.     97 

But  we  will  suppose  necrosis  already  present ;  what 
happens  then  ?  The  tumor  keeps  on  discharging, 
and  in  the  discharge  fragments  of  crumbling  bone 
are  found.  Let  me  say  that  the  extent  of  the  ne- 
crosis is  usually  confined  to  the  size  of  the  perios- 
teal swelling,  so  that  when  death  of  the  bone  has 
once  set  in  you  can  have  some  idea  of  its  limit.  The 
bone  crumbles  away  little  by  little,  presenting  nothing 
in  the  shape  of  a  firm  sequestrum  for  you  to  extract ; 
indeed,  it  seldom  has  the  line  of  separation  from 
sound  bone  which  dead  bone  of  non-syphilitic  origin 
shows,  but  it  simpl}^  chips  off  in  small  flakes  and 
pieces  until  it  has  reached  the  limits  of  the  diseased 
portion,  when,  if  treatment  has  been  properly  pursued, 
it  stops,  granulations  spring  up  from  the  bottom  and 
sides  of  the  cavity,  cicatrization  takes  place,  and  a 
more  or  less  depressed  cicatrix  is  left  behind  to  mark 
the  loss  of  bone. 

When  this  necrosis  occurs  in  the  external  osseous 
framework,  the  results,  although  bad,  are  seldom 
serious  ;  but  when  it  occurs  in  the  internal  bones, 
such  as  the  palatine,  nasal  and  hyoid,  or  in  the  rings 
of  the  trachea — for  cartilage  disappears  as  well  as  bone 
— then  serious  mischief  follows,  not  confined  alone  to 
the  shocking  disfigurement  which  occurs,  but  it  may 
even  endanger  the  patient's  life.  The  same  process 
is  repeated  here  as  in  the  long  bones  ;  the  gummous 
deposit  takes  place  into  and  beneath  the  periosteum, 
stripping  ^he  latter  from  the  bone  ;  necrosis  and  ex- 
5 


9^  VENEREAL   DISEASES. 

foliation  of  bone  follows,  and  when  this  happens 
in  the  palatine  and  nasal  bones  the  oral  and  nasal 
cavities  are  thrown  into  one,  and  the  disease  may  go 
so  far  as  to  attack  the  base  of  the  skull,  causing  coma, 
low  delirium,  and  death.  These  are  the  cases  so  fre- 
quently associated  with  syphilitic  cachexia  ;  and  when 
that  stage  is  reached,  hope  is  about  at  an  end.  You 
may  perhaps  recall  such  a  case  which  I  showed 
you  from  ward  13,  where  the  hard  and  soft  palate 
had  both  disappeared,  the  nasal  bones  had  gone, 
causing  the  nose  to  flatten  out  upon  the  face  ;  where 
necrosis  of  the  vertebrae  at  the  posterior  pharyngeal 
wall  was  present,  and  a  sinus  led  from  the  inferior 
orbital  angle  to  a  mass  of  dead  bone  in  the  lower 
plate  of  the  orbit.  I  called  your  attention  to  the 
condition  of  the  man,  and  to  his  worn-out,  more 
dead-than-alive  look,  and  told  you  then  his  race  was 
nearly  run.  He  died  a  week  after,  in  spite  of  treat- 
ment, gradually  sinking  into  a  low  form  of  delirium 
until  death  released  him  from  his  sufferings. 

These  are  the  cases,  happily  rare,  which  once  in  a 
while  present  themselves  as  if  to  show  what  syphilis 
is  capable  of  doing,  and  there  is  one  more  form  about 
which  I  wish  to  speak  to  you  before  closing  this 
lecture.  This  is  where  syphilis  attacks  the  rings  of 
the  trachea,  and  where,  from  pressure  of  the  gumma 
upon  the  glottis  and  trachea,  death  by  suffocation 
threatens  to  supervene,  rendering  tracheotomy  neces- 
sary to  save  life.     Under  active  and  persistent  treat- 


SYPHILIS  OF  NERVOUS  SYSTEM  AND  BONE.      99 

ment  the  neoplasm  may  disappear,  but  too  often  the 
cartilage  exfoliates  ;  the  rings  disappear,  and  upon 
cicatrization  a  partial  stenosis  of  the  trachea  occurs  ; 
and  this  impediment  to  respiration,  combined  with 
the  exhaustion  so  often  found  in  these  cases,  rarely 
fails  sooner  or  later  to  end  the  patient's  life. 

The  tendons  also  participate  in  this  disease,  and  are 
usually  attacked  in  the  late  stages  by  a  gummous 
deposit  in.  their  sheaths.  While  this  lasts  it  may 
produce  curious  deformities  ;  as,  for  example,  when  it 
occurs  in  the  tendo-Achillis,  it  produces  a  talipes 
equinus,  and  if  in  the  tendons  of  the  flexor  commu- 
nis digitorum  it  imparts  to  the  hand  a  peculiar  claw- 
like look.     Of  course  such  a  hand  is  useless. 

The  symptoms  are  those  of  gummata  elsewhere, 
swelling  and  thickening  of  the  parts,  unattended  by 
much  pain.  They  usually  yield  to  treatment,  but 
sometimes  permanent  contraction  ensues,  rendering 
tenotomy  necessary  in  order  to  restore  the  parts  to 
some  degree  of  usefulness. 

We  have  now  run  over  the  principal  points  in  the 
history  and  course  of  syphilis,  and  I  trust  that  the 
pictures  I  have  sketched  for  you  in  these  lectures 
will  enable  you  to  recognize  all  the  cases  which  you 
will  be  likely  to  see  in  every-day  practice.  The  next 
lecture  will  be  devoted  to  the  treatment  of  syphilis — 
a  very  interesting  subject,  and  to  the  importance  of 
which  I  think  you  are  keenly  alive. 


LECTURE   VIII. 

TREATMENT   OF   SYPHILIS. 

As  regards  the  treatment  of  syphilis,  allow  me  to 
say  at  the  outset  that  it  would  not  come  within  the 
scope  of  these  lectures  to  discuss  pro  or  con  the 
various  methods  which  have  been  in  vogue  since 
syphilis  has  been  recognized  as  a  separate  disease  ; 
and  what  I  therefore  propose  to  do  is,  to  give  you 
the  kind  of  treatment  which  has  best  stood  the  test 
of  time,  and  which  at  the  present  day  is  the  most 
approved.  With  this  object  in  view  I  shall  divide 
the  subject  into  the  two  principal  groups  of  internal 
and  external  treatment,  and  give  you  as  I  go  along 
the  appropriate  prescriptions  for  each. 

In  the  first  place,  as  regards  the  treatment  of  the 
initial  lesion.  I  have  already,  when  speaking  of  this 
form  of  syphilis  in  a  previous  lecture,  given  you  the 
plan  most  deserving  of  adoption,  and  will  therefore 
do  no  more  than  refresh  your  memory  upon  some  of 
the  principal  points  to  which  I  then  called  your  atten- 
tion. 

In  the  first  place,  do  not  cauterize  the  initial  lesion 
unless  it  be  attacked  by  phagedena,  when  it  may  be 


TREATMENT   OF  SYPHILIS.  lOI 

admissible  ;  but  when  it  is  uncomplicated,  cauterizing 
it  does  110  good ;  on  the  contrary,  it  does  harm.  In 
the  second  place,  do  not  treat  it  by  the  internal  use 
of  mercury,  for  the  reason  that  this  metal  retards  the 
appearance  of  the  early  syphilides,  and  leaves  the  sur- 
geon at  sea  as  to  when  to  expect  subsequent  lesions, 
and  what  to  look  for,  and  also  because  its  use  some- 
times prevents  the  surgeon  from  deciding  with  cer- 
tainty upon  the  nature  of  doubtful  ulcers  ;  and  when, 
the  period  of  probation  passing  by,  and  no  symptoms 
appearing,  he  assures  his  patient  that  nothing  further 
is  to  be  expected,  his  promises  of  future  indemnity 
are  apt  to  be  rudely  dispelled  by  the  appearance  of 
the  long-delayed  syphilides  some  months  later.  In 
addition  to  this,  waiting  until  the  syphilides  appear 
does  not  injure  the  patient's  chances  of  ultimate  re- 
covery. Treat  the  initial  lesion,  then,  by  the  rules 
laid  down  in  Lecture  III. 

When  the  syphilides  appear,  however,  and  the 
time  for  internal  medication  arrives,  what  shall  we 
do  ?  In  the  early  stages  of  syphilis,  you  remember, 
the  symptoms  are  multiple  and  polymorphous,  and 
when  the  six  weeks  of  incubation  have  elapsed,  your 
patient  blazes  out  with  an  erythema  of  skin  and 
mucous  membranes,  papules  in  the  scalp,  mucous 
patches  of  the  tongue  and  threat,  alopecia,  hemi- 
crania,  and  universal  induration  of  the  glands  of  the 
body.  Preceding  these  symptoms  there  probably 
has  been  some  febrile  excitement,  which  disappears 


102  VENEREAL   DISEASES. 

as  the  eruption  shows  itself.  Now  is  the  time  for  the 
use  of  mercury  ;  and  let  me  tell  you  that,  of  all  the 
drugs  at  your  command  for  the  treatment  of  syphilis, 
there  is  not  one  that  will  take  its  place.  Dismiss 
from  your  minds  the  senseless  abuse  of  mercury 
which  some  writers  indulge  in,  and  remember  that 
the  surgeon  who  neglects  to  use  this  mineral  in  treat- 
ing syphilis  does  injustice  both  to  his  patient  and  to 
himself;  for  although  some  mild  cases  of  syphilis  may 
and  do  recover  without  its  use,  the  risk  run  is  greater 
than  any  prudent  surgeon  should  incur.  Know  what 
to  expect  from  your  drug,  use  it  properly,  and  de- 
pend upon  it  that  those  two  points  well  carried  out, 
the  mercury  will  do  no  harm  either  in  the  present  or 
the  future ;  on  the  contrary,  it  will  do  good. 

In  the  early  stages  of  syphilis,  i.  e.,  through  the 
period  of  erythemata  and  papul?e,  the  preparation 
that  I  use,  I  was  going  to  say  to  the  exclusion  of 
almost  everything  else,  is  the  following  : 

^ .      Mass.  hydrargyri gr-  ij- 

Ferri  sulphatis  exsiccat gr-  i« 

Fiat  pil.  no.  i. 

M. 

Sig. — Three  to  six  daily. 

I  usually  begin  with  one  three  times  daily,  after 
meals,  gradually  increasing  the  number  to  two,  three 
times  daily,  as  occasion  requires. 


TREATMENT  OF  SYPHILIS.  103 

The  bichloride  of  mercury  is  the  old  and  time-hon- 
ored preparation  which  has  been  usually  given,  I 
very  seldom  use  it,  because  in  my  hands  it  has  been 
apt  to  produce  its  toxical  qualities,  griping  of  the 
bowels,  diarrhoea,  and  sponginess  of  the  gums,  just 
when  it  is  most  needed.  Still,  in  some  cases  it  an- 
swers well  enough,  and  when  used  it  had  better  be 
given  in  pill  form,  thus  : 

'^ .      Hydrargyri  bichloridi gr.  yV"i 

Saponis q.  s. 

Ut  fiat  pil.  una. 
Sig. — One,  thrice  daily  after  meals. 

In  order  to  check  its  action  upon  the  bowels,  from 
i~2  grain  of  opium  may  be  added  to  each  pill. 

Another  form,  one  much  esteemed  by  Ricord,  is 
the 

PROTIODIDE    OF    MERCURY    PILL. 

]^.      Hydrargyri  protiodidi gr.  -J-^ 

Extracti  gentianas q.  s. 

Ut  fiat  pil.  no.  i. 

Sig. — One,  thrice  daily  after  meals. 

But  of  all  these  preparations  of  mercury,  as  already 
stated,  I  much  prefer  the  one  first  given,  the  blue 
mass  and  iron  pill,  for  its  efficacy  and  for  the  toler- 
ance which  the  system  show^s  to  it.     The  addition  of 


I04  VENEREAL   DISEASES. 

the  Iron  is  of  value  not  only  in  increasing  the  action 
of  the  mercury,  but  for  its  own  effect  as  a  tonic. 

Now  comes  the  question  :  how  long  shall  the  mer- 
cury be  continued  ;  how  much  shall  be  given  ;  and 
under  what  circumstances  shall  it  be  increased,  dix 
minished,  or  stopped  altogether?  To  the  first  point 
I  reply,  until  the  symptoms  disappear  or  the  drug 
produces  toxical  symptoms  ;  by  that  I  mean  distur- 
bance of  the  digestion,  diarrhoea,  sponginess  of  the 
gums,  and  salivation.  With  regard  to  this  last,  I  wish 
to  impress  upon  your  minds  the  fact  that  its  occur- 
rence is  a  hindrance,  not  a  benefit  to  treatment,  inas- 
much as,  when  present,  the  mercurial  has  to  be  stop- 
ped and  so  much  time  wasted.  Avoid  then,  carefully, 
any  approach  to  salivation  ;  but  should  such  an  acci- 
dent occur,  suspend  all  antisyphilitic  treatment  and 
place  your  patient  upon  the  following  prescription  : 

3  •     Potassre  chlorat 3  i- 

Aquae |  vi. 

M. 

Sig. — Locally  as  a  mouth-wash,  and  internally  in  tea- 
spoonful  doses,  four  or  five  times  daily. 

This  checks  the  sponginess  of  the  gums,  the  fetor 
of  the  breath,  and  the  flow  of  the  saliva,  which  are 
the  three  symptoms  attending  this  form  of  mercurial 
intoxication. 

Two  other  remedies  have  been  used,  both  of  which 
may  be  of  service.     They  are  belladonna,  or  its  alka- 


TREATMENT  OF  SYPHILIS.  105 

loid  atropine,  and  dilute  nitric  acid.     They  are  usually 
given  as  follows  : 

I^.     Tinct.  belladonnae 3  iv. 

Aquae 3  ij. 

M. 

Sig. — Teaspoonful  four  times  daily,  in  water. 

If  you  use  atropine  instead  of  belladonna,  give  the 
following  : 

^ .     Atropine g^-  To 

Alcoholis , 2  ss. 

Aquc^ q.  s,  ad  I  ij. 

Sig. — Teaspoonful  three  or  four  times  daily. 

With  the  preparations  of  belladonna  use  the  solu- 
tion of  the  chlorate  of  potash  given  above  as  a  wash. 
The  dilute  nitric  acid  you  will  oftentimes  find  of 
benefit  in  those  cases  where  the  sponginess  of  the 
gums  is  so  excessive  as  to  threaten  the  dropping  out 
of  the  teeth,  and  should  be  given  both  internally  and 
locally. 

^ .     Ac.  nit.  dil 3  iv. 

Aquce ^  ij. 

Sig. — Teaspoonful  four  times  daily,  in  water ;  also  use 
locally. 

If,  however,  you  give  mercury  prudently  and 
properly,   carefully  watching  your  patient,   no  such 

5^ 


.* 


I06  VENEREAL   DISEASES. 

accident  as  I  have  just  detailed  need  occur ;  and,  in- 
deed, you  will  oftentimes  be  surprised  to  see  how 
tolerant  the  system  is  in  syphilis  of  even  large  doses 
of  this  mineral.  I  have  often  given  in  these  early 
stages  of  the  disease  lO  to  12,  and  even  14  grains  a 
day  for  several  weeks  at  a  time,  without  producing 
any  systemic  disturbance  whatever;  but  it  was  in 
those  cases  where  the  attack  was  severe,  and  I  was 
careful  to  keep  the  patient  under  rigid  observation. 
In  average  cases,  6  to  8  grains  daily  will  be  sufficient 
to  dispel  the  symptoms. 

As  to  the  circumstances  which  shall  impel  us  to 
increase,  diminish,  or  altogether  stop  the  mercurial, 
they  may  be  disposed  of  in  a  few  words.  If  the 
symptoms  be  obstinate  and  slow  to  disappear,  and  if, 
at  the  same  time,  the  patient  stands  his  treatment 
well,  the  drug  may  be  gradually  increased  until  the 
symptoms  give  way  or  the  patient  begins  to  show  a 
slight  red  line  at  the  edges  of  the  gums.  Should 
this  latter  occur  before  the  disappearance  of  the 
syphilitic  lesions,  the  mercury  must  be  suspended  for 
a  few  days,  and  when  it  is  recommenced,  a  different 
preparation  given  from  the  one  formerly  used.  It  is 
seldom,  however,  that  the  earlier  manifestations  re- 
sist a  determined  attack  with  this  mineral. 

As  soon  as  the  symptoms  have  disappeared  so  as 
to  leave  no  staining  of  the  skin  or  other  trace  of  their 
presence  behind  them,  it  is  well  to  discontinue  the 
use  of  the  mercurial  for  the  following  reasons  :  first, 


TREATMENT  OF  SYPHILIS.  lO/ 

to  avoid  too  great  a  tolerance  of  the  system  to  the 
drug ;  and  secondly,  to  enable  us  to  determine  whether 
other  lesions  are  about  to  follow  or  not.  Upon  this 
last  point  let  me  dilate  a  little,  even  at  the  risk  of 
seeming  tedious,  in  order  to  avoid  misunderstanding 
upon  your  part.  We  will  take,  for  example,  one  of 
the  many  cases  which  I  have  already  shown  you  from 
the  wards — -say  this  one,  of  a  papular  syphilide. 
As  soon  as  the  manifestations  have  disappeared  from 
the  skin,  leaving  no  trace  behind  them,  the  mercurial 
treatment  will  be  discontinued  and  the  man  will  be 
placed  upon  tonics.  Now,  if  you  will  remember  what 
I  have  told  you  when  we  were  speaking  of  the  syphi- 
lides  of  the  skin,  you  will  recollect  that  there  is  a 
period  of  incubation,  shorter  or  longer  as  the  case 
may  be,  between  the  appearance  of  the  various  mani- 
festations, and  if  you  continue  your  treatment  after 
the  first  train  of  symptoms  have  disappeared,  you 
delay  the  occurrence  of  the  subsequent  ones.  But 
suppose  you  intermit  your  treatment  instead  of  con- 
tinuing it,  and  the  period  of  probation  passes  without 
the  expected  symptoms  appearing — it  shows  you  that 
the  disease  is  losing  its  strength  (^for  the  amount  of 
mercury  you  have  already  given  for  previous  symp- 
toms would  not  prevent  ihe  subsequent  manifesta- 
tions if  the  syphilis  were  still  very  active),  and  you 
would  be  justified  in  supposing  that  the  disease  was 
on  the  wane,  and  the  longer  the  time  which  elapses 
between    the  various    stages,  the   more  hopeful  the 


I08  VENEREAL   DISEASES. 

prognosis.  BiU  bear  in  mind  that  as  long  as  any 
symptoms  last,  no  matter  hozv  slight,  so  long  must  the 
treatment  be  continued ;  and  also  that  it  must  be  re- 
newed, if  previously  discontinued,  should  fresh  mani- 
festations recur. 

This  touches  upon  internal  treatment  only ;  but 
occasionally  some  lesions  require  a  topical  as  well  as  a 
constitutional  medication.  Of  these,  mucous  patches 
head  the  list.  The  early  lesions  of  the  skin,  of  course, 
require  no  local  applications ;  it  is  only  where  the 
erythematous  blotches  and  papules  invade  skin  and 
mucous  membrane  together,  as,  for  example,  at  the 
angle  of  the  mouth  and  eyelids,  or  in  other  portions 
of  the  body  which  combine  heat  and  moisture,  such 
as  the  pourtour  of  the  anus,  the  labiae  vulvae,  the 
scrotum  and  penis,  the  toes,  the  buttocks  and  arm-pits, 
that  topical  treatment  becomes  requisite.  The  two 
best  remedies  for  these  lesions  are  powdered  calomel 
and  the  application  of  the  nitrate  of  silver,  either  in  the 
solid  stick  or  as  a  saturated  solution.  But  do  not  for- 
get the  most  important  point  of  all :  keep  the  parts  dry 
and  clean,  else  your  treatment  will  be  of  little  avail. 

When  the  mucous  patches  are  seated  in  the  throat, 
or  on  the  lips,  tongue,  and  lining  membrane  of  the 
cheeks,  the  application  of  the  nitrate  of  silver  is  gen- 
erally the  most  efficacious  ;  and  when  the  lesions  are 
seated  low  down  in  the  pharynx  a  spray  of  a  weak 
solution  of  nitrate  of  silver  (gr.  v.  to  aq.  3  i.)  will  be 
of  advantage. 


TREATMENT  OF  SYPHILIS.  109 

As  the  later  stages  of  the  disease  are  reached,  the 
treatment  undergoes  certain  modifications  ;  the  one 
best  calculated  to  promote  a  cure  is  that  known  as 
the  mixed  treatineiit.  This  consists  of  mercury  and 
the  iodide  of  potassium,  used  either  separately  or 
in  combination,  and  is  given  in  those  stages  of  the 
disease  which  are  ulcerative  in  their  character.  I 
much  prefer  giving  the  two  separately,  for  facility  of 
exhibition,  and  because  either  one  can  be  increased 
without  increasing  the  other.  The  two  preparations 
of  mercury  most  in  use  are  the  protiodide  (internally), 
and  the  ordinary  mercurial  ointment,  or  oleate  of 
mercury,  as  an  inunction  to  the  skin.  If  the  internal 
use  of  the  drug  be  decided  upon,  the  protiodide 
should  be  given  once  daily,  in  from  a  half  to  one 
grain,  and  the  iodide  of  potassium  in  two  daily  doses, 
thus  : 

15. .     Hydrarg.  protiod gr.  -J— gr.  i. 

Ext.  gentianae q.  s. 

Ut  ft.  pil.  una. 

Sig. — Once  daily,  after  mid-day  meal. 

And— 

5 .     Kali  iodidi ,-, 3  ij. 

Tinct.  cinchonce  comp., 

Tinct.  gentians aa   |  ss. 

Aquae q.  s.  ad  ^  ij. 

M. 

Sig. — Teaspoonful  well  diluted  with  water  twice  daily, 
morning  and  evening,  after  meals. 


no  VENEREAL   DISEASES. 

Should  you  elect  to  combine  the  mercurial  and 
the  iodide  of  potassium  in  one  dose,  you  will  find 
the  following  prescription  a  good  one  : 

IJ .      Hydrarg.  bichlor gr.  f -i. 

Or— 

Hydrarg.  biniodidi gi"*  f -i* 

Kali  iodidi 3  ij. 

Tinct.  gentianae, 

Aquae ' aa   |  i. 

M. 
Sig. — Teaspoonful  well   diluted  with  water  twice   daily, 
morning  and  evening,  after  meals. 

All  of  these  remedies  should  be  given  after  eating 
in  preference  to  before,  because  the  iodide  of  potas- 
sium sometimes  produces  intestinal  disturbance  if 
given  upon  an  empty  stomach. 

But,  we  will  suppose  you  do  not  wish  to  give 
mercury  internally  by  the  mouth,  but  prefer  some 
other  mode  of  administration.  What  ways  are  open 
to  you  ?  There  are  three:  first,  by  inunction,  i.e.^ 
friction  on  the  skin,  of  some  oleaginous  or  fatty 
preparation  containing  mercury ;  second,  by  mer- 
curial vapor-baths ;  and  third,  by  subcutaneous 
injections. 

The  first  of  these  methods,  by  inunction,  although 
a  most  excellent  way  of  getting  a  rapid  and  at  the 
same   time   thorough   effect   of  mercury,  is  open  to 


TREATMENT  OF  SYPHILIS.  Ill 

the  serious  objection  of  uncleanliness,  and  with 
justice,  as  the  old-fashioned  way  of  smearing  the 
ointment  over  the  entire  body  in  divided  doses  kept 
the  body  and  Hnen  in  a  constant  state  of  greasiness 
and  dirt.  This,  in  recent  times,  has  been  much 
improved  upon  by  the  use  of  the  oleate  of  mercury  ; 
but  this,  though  better  than  the  unguent,  hydrarg.  of 
the  pharmacopoeia,  is  repugnant  to  many  persons 
who  are  careful  about  the  cleanliness  of  their  per- 
sons. .  To  obviate  this,  and  to  reduce  the  dirty 
feeling  which  any  greasy  substances  impart  to  the 
skin,  I  have  for  some  time  past  used  the  oleate  of 
mercury,  20,^  strength,  on  the  soles  of  the  feet,  to 
the  exclusion  of  the  ordmary  mercurial  ointment, 
in  the  following  manner  : 

The  patient  is  directed  to  bathe  the  feet  thor- 
oughly in  hot  water  the  night  on  which  the  first 
inunction  is  made,  when  half  a  drachm  of  the  20^^ 
oleate  of  mercury  is  rubbed  briskly  into  the  sole  of 
the  right  foot ;  this  is  repeated  the  next  night  on  the 
left  foot,  and  so  on  alternate  nights  the  right  and  left 
foot  is  anointed  with  half  a  drachm  of  the  prepara- 
tion. This  may  be  increased  to  a  drachm,  or  more, 
if  the  patient  stands  the  mercurial  well.  The  same 
stocking's,  which  should  be  of  wool  or  some  toler- 
ably thick  material,  are  worn  continuously-  niglit 
and  day,  for  one  week,  at  the  expiration  of  which 
time  the  feet  may  be  thoroughly  cleansed  with  hot 
water  and  soap,  and  an  intermission  of  three  or  four 


112  VENEREAL   DISEASES. 

days  elapse  before  renewing  this  same  process  for  a 
similar  length  of  time.  The  iodide  of  potassium 
should  be  kept  up  during  the  period  of  inunction 
as  well  as  during  the  intermission,  in  three  daily- 
doses. 

The  advantage  of  this  method  is  twofold  :  first, 
as  regards  cleanliness  ;  second,  as  to  efficacy.  In- 
stead of  smearing  the  body  all  over  and  keeping  it 
in  a  continually  dirty  state,  the  whole  of  this  dis- 
agreeable feature  of  the  treatment  is  confined  to  the 
feet,  and  the  repeated  dose  is  in  a  process  of  con- 
tinual absorption,  inasmuch  as  every  movement  that 
the  patient  makes  in  walking  serves  to  rub  the 
ointment  into  the  skin  of  the  feet,  and  absorption 
does  take  place  notwithstanding  the  thickness  of 
the  cuticle  in  this  part. 

The  second  method,  by  the  vapor  bath,  is  equally 
efiicacious,  and  not  open  to  the  same  objections  that 
the  inunction  process  is.  The  patient  may  be  sent 
to  one  of  the  regular  establishments  where  these 
baths  are  given,  or,  if  preferred,  it  may  be  given  in 
the  patient's  own  house.  The  apparatus  requisite 
for  the  purpose  is  the  portable  vapor-bath,  sold  in 
the  shops  under  the  name  of  *'  Lee's  Mercurial  Vapor 
Bath,"  or  the  American  modification  of  the  same — a 
long,  sleeveless  flannel  night-shirt,  made  to  reach  to 
the  patient's  feet,  and  an  India-rubber  mackintosh  of 
the  same  pattern  as  the  flannel  shirt,  both  of  which 
should  close  tightly  round  the  neck,  leaving  the  head 


TREATMENT  OF  SYPHILIS.  II3 

exposed,  and  a  round  stool  for  the  patient  to  sit 
upon.  The  flannel  shirt  and  the  mackintosh  should 
be  made  large  enough  to  allow  the  patient  to  sit 
upon  the  stool  inside  of  both.  The  vapor-bath  is  a 
cylinder  of  tin  or  of  wire  gauze,  enclosing  within  it 
an  alcohol  lamp.  The  upper  portion  of  the  cylinder 
holds  a  plate,  which  is  hollowed  out  in  the  shape  of 
a  gutter  at  its  outer  circumference  ;  the  middle  por- 
tion is  elevated  above  this  gutter,  and  contains  a 
shallow  depression  or  cup.  The  patient,  being 
stripped  and  dressed  in  his  shirt  and  mackintosh,  is 
seated  upon  the  stool  which  is  included  within  his 
bath-clothing,  and  the  whole  is  carefully  tucked  in  at 
the  bottom,  to  prevent  the  escape  of  any  vapor.  The 
bath  is  prepared  in  the  following  manner:  water  is 
poured  into  the  gutter  of  the  plate  at  the  upper  por- 
tion of  the  cylinder,  and  the  mercurial  is  placed  on 
the  shallow  cup  at  the  apex,  in  the  middle  ;  the  lamp 
is  then  lighted,  and  the  whole  apparatus  placed 
under  the  stool  upon  which  the  patient  is  sitting. 
The  lamp  is  so  arranged  that  the  flame  striking 
against  the  plate  at  the  top  causes  evaporation  of 
the  water,  and  the  heat  throws  the  patient  into  a 
profuse  perspiration,  producing  a  steam  vapor-bath. 
As  soon  as  the  water  has  evaporated,  the  mercury, 
in  its  turn,  is  volatilized  and  readily  absorbed  by  the 
skin.  As  soon  as  all  the  mercury  has  disappeared, 
the  light  is  put  out,  and  the  patient  is  left  inside  his 
waterproof  clothing   until   the  body  begins  to   cool 


114  VENEREAL  DISEASES. 

slightly ;  he  should  then  be  taken  from  his  stool,  the 
waterproof  cloak  removed,  while  the  flannel  shirt  is 
retained,  and  he  should  be  covered  up  with  blankets 
until  all  perspiration  has  ceased  and  the  body  has 
become  cool  and  tolerably  dry,  when  he  may  put  his 
clothes  on  again.  This  is  supposing  the  bath  to  be 
given  in  the  day,  but  bedtime  is  the  best  period  of 
administration,  when  the  patient  may  go  to  bed  at 
once  and  remain  there. 

A  good  substitute  for  the  lamp  is  an  ordinary 
chafing-dish,  the  tin  or  zinc  plate  of  which  may  be 
replaced  by  an  iron  saucer  to  contain  the  water,  and 
this,  upon  evaporation  of  the  >water,  becomes  thor- 
oughly heated.  When  this  is  accomplished,  the 
mercury  may  be  placed  upon  the  still  hot  plate,  pro- 
ducing the  same  result  which  is  attained  by  the  regu- 
lar apparatus. 

The  preparation  of  mercury  used  is  either  calomel 
or  the  black  oxide,  the  former  being  given  in  20  to 
40  grains  to  each  bath,  and  the  latter  from  30  to  60. 

The  time  required  for  the  bath  varies  from  thirty 
to  forty  minutes,  and,  barring  the  length  of  time  it 
takes,  is  one  of  the  nicest  and  cleanest  ways  of  intro- 
ducing mercury  into  the  system,  besides  being  of 
easy  application. 

The  method  by  subcutaneous  injection  is  very 
little  used  in  private  practice,  owing  to  the  trouble  of 
administration  and  the  pain  attendant  upon  it.  It  is 
done  by  injecting  the  solution    containing   mercury 


TREATMENT  OF  SYPHILIS,  II 5 

beneath  the  skin,  which,  besides  being  painful,  is 
frequently  followed  by  abscesses  at  the  point  of  in- 
jection. Calomel  is  the  agent  usually  selected,  and  is 
given  in  doses  varying  from  -^^  \.o  \  2,  grain  at  each 
injection. 

The  local  treatment  of  the  ulcerative  syphilides, 
although  not  so  important  as  the  constitutional  treat- 
ment, is  decidedly  necessary  and  useful.  Those  of 
the  skin,  if  the  crust  has  been  removed,  should  be 
dressed  with  mercurial  ointment  spread  upon  a  cloth. 
It  is  better,  however,  to  leave  the  crust  on,  if  it  be 
firmly  adherent,  as  it  makes  the  best  protection  for 
the  part,  and  the  underlying  ulcer  heals  up  under  the 
administration  of  the  mercury  and  iodide  of  potas- 
sium. The  ulcerations  occurring  in  the  throat  and 
mouth  should  be  treated  with  nitrate  of  silver  (40 
grains  to  one  fluid  ounce  of  water),  carbolic  acid 
(crystals  gr.  xxx.  to  water  3  i.)  or  nitric  acid  (ac.  nit. 
c.  p.  Tit  XXX.  to  water  3  i.).  If  the  lesions  are  deeply 
seated  in  the  throat,  or  in  the  posterior  nasal  cavity, 
they  may  be  reached  by  a  spray  of  the  above  solutions. 

In  necrosis  of  the  nasal  and  palatine  bones  the 
parts  should  be  thoroughly  washed  out  with  warm 
water,  injected  through  a  posterior  nasal  syringe, 
and  afterward  sprayed  with  the  solutions  given 
above,  and  patience  exercised  until  the  dead  bone 
comes  away  under  internal  treatment. 

I  now  wish  to  say  a  few  words  to  you  with  regard 
to  the  administration  of  your  remedies,  because  upon 


Il6  VENEREAL   DISEASES. 

the  thoroughness  with  which  you  use  them  will  the 
advantage  of  your  treatment  largely  depend.  With- 
out at  all  advising  you  to  be  rash,  I  wish  you  to  be 
bold,  and  to  remember  that  in  face  of  such  a  disease 
as  syphilis  you  cannot  afford  to  trifle.  When  using 
mercury,  watch  your  patient  carefully,  be  on  the  look- 
out for  toxical  symptoms,  but  do  not  hesitate,  if 
occasion  requires,  to  push  your  medicines  to  the 
utmost  limit  which  the  patient  will  tolerate.  I  believe 
more  harm  is  done  than  is  generally  known,  in  many 
cases,  from  the  surgeon  being  afraid  to  use  mercury 
in  sufficient  quantities  to  control  the  disease,  and  in 
syphilis,  you  must  recollect,  mercury,  instead  of  act- 
ing as  a  depressant,  seems  to  possess  the  properties 
of  a  tonic — indeed,  it  is  the  sheet-anchor  in  treatment. 
The  same  is  true  of  the  iodide  of  potassium,  so  far  as 
regards  its  tonic  property  ;  of  little  if  any  value  in 
the  earlier  stages  of  syphilis,  in  the  later  (ulcerative) 
periods  it  is  invaluable,  but  only  as  an  adjuvant;  it 
never  will  take  the  place  of  mercury.  Give  it  at  the 
commencement  in  lO  grain  doses,  gradually  increas- 
ing the  amount  until  the  symptoms  are  controlled  or 
iodism  occurs.  This  is  characterized  by  coryza,  lachry- 
mation,  and  an  eruption  of  papules  and  pustules  on  the 
face  and  shoulders  (acne),  and  occasionally,  though 
very  rarely,  by  blebs.  As  to  the  amount,  it  may  perhaps 
surprise  you  to  hear  how  much  of  this  salt  patients 
with  advanced  syphilis  will  stand  ;  it  is  sometimes 
enormous.     For  example,  in  the  case  of  Quinn,  the 


TREATMENT  OF  SYPHILIS.  11/ 

patient  I  showed  you  with  nervous  syphilis,  in  whom 
the  symptoms  were  distortion  of  the  face  and  par- 
alysis of  the  leg  and  arm  of  one  side,  attended  with 
severe  pain  in  the  head  and  insomnia,  the  amount 
given  was  120  grains  at  each  dose,  and  this  was 
repeated  three  times  daily.  In  addition  to  this,  he 
used  a  drachm  of  mercurial  ointment  every  night  by 
inunction,  and  perhaps  you  remember  that  when,  after 
ten  days  of  such  treatment,  I  presented  him  to  you 
again,  the  facial  paralysis  had  almost  entirely  disap- 
peared, the  arm  and  leg  had  regained  a  great  deal  of 
their  power,  and  he  had  lost  much  of  the  cachectic 
appearance  which  he  formerly  showed.  And  yet  the 
case  at  first  looked  anything  but  promising,  and 
only  shows  the  importance  in  these  advanced  cases 
of  large  doses  of  the  salt.  Large  as  the  above 
amount  is,  it  is  not  as  great  as  I  have  sometimes 
used,  and  I  will  formulate  here  some  axioms  which 
may  be  of  use  for  you  to  remember  in  the  treatment 
of  syphilis  : 

Mercury  is  the  main-stay  in  treatment ,  not  only 
in  the  earlier  but  in  the  later  stages  as  well. 

Iodide  of  potassium  is  of  little  service  in  the  earlier 
stages  ;  in  the  later  stages,  altJiotigh  of  extreme  value ^ 
it  only  assists  ijt  dispelling  symptoms ;  to  produce 
radical  effects,  it  sJiould  be  combined  with  mercury. 

In  giving  both  mercury  and  iodide  of  potassiunty 
watch  your  patient  zvell  to  obviate  the  occurrence  of 
toxical  symptomSy  a?id  do  not  hesitate  to  tcse  either 


II 8  VENEREAL  DISEASES. 

remedy  in  sufficient  amount  to  dispel  the  symptoms, 
no  matter  what  the  requisite  dose  may  be. 

You  will  oftentimes  find  in  the  graver  forms  of 
the  disease,  such  as  gummata  or  nerve-syphilis,  that 
doses  of  20  or  30  grains  produce  little  effect ;  carry 
your  dose  up  to  50  or  60  grains,  and  you  will  have 
the  gratification  of  seeing  your  patient  improve  at 
once.  What  the  mode  of  action  is  I  cannot  tell,  for 
curiously  enough,  when  given  in  large  doses,  nearly 
all  the  iodide  of  potassium  given  can  be  collected  in 
the  urine ;  thus,  if  a  dose  of  60  grains  be  given,  40  of 
it  will  be  excreted,  leaving  20  to  be  absorbed,  and 
yet  if  you  give  only  20  grains  instead  of  60,  it  makes 
no  sort  of  impression  on  the  disease. 

It  sometimes,  though  rarely,  happens  that  the 
patient,  through  some  idiosyncrasy,  cannot  toler- 
ate iodide  of  potassium ;  in  those  cases,  the  simple 
tincture  of  iodine  may  be  used  as  a  good  substi- 
tute. It  should  be  given  in  the  following  prescrip- 
tion : 

5 .     Tinct.  iod |  ss. 

Syr.  fusci 3  iv. 

M. 
Sig. — One  teaspoonful,  well  diluted  with  water,   three 
times  daily,  after  eating. 

This  preparation  is  usually  well  borne  by  the  stom- 
ach, and  is  by  no  means  unpalatable. 


TREATMENT  OF  SYPHILIS.  1 19 

The  amount  of  this  should  also  be  increased  pre- 
cisely in  the  same  way  as  the  iodide  of  potassium, 
although  the  amount  required  will  probably  not  be 
as  large. 

When  we  were  discussing  the  natural  history  and 
symptoms  of  syphilis,  I  spoke  to  you  about  what  is 
known  as  syphilitic  cachexia,  a  condition  character- 
ized by  lardaceous  changes  in  the  viscera.  This  is  a 
very  grave  and  serious  disease, — serious,  because  the 
system  refuses  absolutely  to  absorb  either  food  or 
medicine.  When  this  occurs,  the  treatment  by  mer- 
cury and  iodide  of  potassium  has,  if  continued,  to  be 
combined  with  tonics  and  stimulants,  which  should  be 
given  with  a  liberal  hand.  Of  the  tonics,  the  principal 
ones  are  the  ferruginous  preparations,  either  alone 
or  combined  with  cod-liver  oil,  and  among  the 
stimulants,  the  more  diffusible  ones,  such  as  cham- 
pagne and  brandy  ;  but  when  a  patient  arrives  at 
this  stage  of  the  disease  there  is  little  hope,  and  all 
that  there  is  left  for  the  surgeon  to  do  is  to  make 
the  road  to  the  grave  as  easy  as  possible. 

As  regards  the  duration  of  treatment  in  the  later 
stages,  it  must  of  necessity  be  prolonged,  as  the 
symptoms  are  more  obstinate  in  character  than  in 
the  early  part  of  the  disease.  The  patient  should  be 
prepared  to  continue  his  treatment  for  a  year,  and 
longer  if  occasion  requires  ;  and  this,  too,  even  if  all 
symptoms  have  disappeared,  varying  in  this  regard 
from  the  treatment  given  in  the  early  periods  of  tlie 


I20  VENEREAL   DISEASES. 

disease.  After  treatment  by  anti -syphilitic  reme- 
dies has  been  continued  as  long  as  the  surgeon  deems 
necessary,  the  patient  should  be  subjected  to  a  thor- 
ough course  of  tonics,  in  order  to  complete  what  the 
mercury  and  iodide  of  potassium  have  begun. 

Before  closing  this  lecture,  let  me  say  a  few  words 
to  you  in  regard  to  prognosis.  In  the  majority  of 
cases  it  is  good  ;  patients  recover  entirely  from  their 
disease,  oftentimes  without  showing  any  of  the  seri- 
ous lesions  such  as  you  meet  with  in  the  wards  of 
hospitals,  and  examples  of  which  I  have  already 
shown  you.  By  recovery,  I  mean  that  patients  show, 
after  the  disease  has  run  through  a  certain  course, 
no  further  symptoms  of  syphilis,  even  though  they 
have  been  kept  under  observation  for  several  years ; 
and  should  they  marry,  their  offspring  show  no 
sign  or  taint  of  disease  so  far  as  syphilis  is  con- 
cerned. It  is  not  in  the  acquired  form  of  syphilis 
that  fatal  results  occur  so  much  as  in  the  hereditary 
form,  where  the  mortality  is  large,  and  where  even, 
should  the  child  survive  to  puberty,  it  is  hable 
throughout  its  whole  life  to  show  symptoms  of  its  in- 
herited malady. 

In  short,  you  may  accept  the  following  rules  as  a 
tolerably  good  guide  in  cases  of  acquired  syphilis  : 

The  average  case  of  syphilis  runs  its  course  in  from 
eigJiteen  to  tiventy-fonr  months. 

Under  proper  and  careful  treatment^  the  graver 
forms  of  the  disease  seldom  occur. 


TREATMENT  OF  SYPHILIS.  121 

After  the  disease  has  apparently  run  its  course,  and 
anti-syphilitic  treatment  has  been  suspended,  the  pa- 
tients should  be  kept  under  occasional  observation  for 
another  eighteen  months,  and  if  in  that  time  no  syinp- 
toms  make  their  appearance,  they  may  make  their 
minds  easy  as  to  the  ftiture.  This,  you  see,  embraces 
a  period  of  three  and  a  half  years,  half  of  which  is 
devoted  to  the  disease y  a?id  the  other  half  to  watching 
for  further  developments. 

These   rules,   you   understand,   are  not    absolute ; 
indeed,  none  such  can  be  given,  but  I  believe  they 
will  serve  as  tolerably  safe  guides  for  you  to  follow. 
6 


LECTURE   IX. 

INFANTILE   SYPHILIS   AND   ITS   TREATMENT. 

We  have  heretofore  considered  only  the  various 
phases  of  acquired  syphilis.  To-day's  lecture  will  be 
devoted  to  a  consideration  of  the  infantile  and  here- 
ditary forms  of  the  disease. 

Hereditary  syphilis  may  be  divided  into  two  prin- 
cipal groups  :  first,  where  it  occurs  at  or  shortly 
after  birth  ;  and  secondly,  where  it  shows  itself  during 
childhood  and  adult  life.  There  seems  to  be  two 
notable  periods  of  explosion — viz.,  at  birth  and  at 
the  period  of  puberty.  We  will  commence  with  the 
first  of  these — syphilis  at  or  shortly  after  birth. 

When  the  disease  shows  itself  at  birth,  the  child 
may  be  either  born  dead,  or,  if  alive,  it  usually 
succumbs  in  the  course  of  a  few  days.  The  body  is 
covered  with  large  bullae,  filled  with  serum  mixed 
with  blood.  These  bullae  speedily  break,  evacuate 
their  contents,  and  the  epidermis  covering  them 
exfoliates,  leaving  a  red,  denuded  surface  beneath. 
This  constitutes  what  is  known  as  pemphigus  neona- 
torum syphiliticum.  When  the  disease  in  the  mother 
is  not  very  far  advanced,  the  child  may  be  born,  to 


INFANTILE  SYPHILIS— ITS  TREATMENT      1 23 

all  appearances,  sound  and  healthy,  not  developing 
any  signs  of  the  disease  until  some  weeks  or  even 
months  after  birth.  Of  course,  the  longer  the  symp- 
toms are  delayed,  the  greater  are  the  child's  chances 
of  viability. 

Syphilis  in  the  infant  appears  almost  always  within 
the  first  six  months  of  extra-uterine  life  ;  in  the  great 
majority  of  cases,  within  the  first  three.  After  a  time 
the  child  loses  its  plump  and  well-nourished  look, 
becomes  thin  and  querulous,  refuses  the  breast,  and 
an  eruption  of  the  erythemato-papular  variety  ap- 
pears upon  the  body,  legs,  and  arms,  particularly  upon 
the  soles  of  the  feet  and  the  palms  of  the  hands. 
Conjoined  with  this  are  mucous  patches  of  the  mouth, 
throat,  axillae,  and  about  the  anus  and  genitals.  The 
child  is  afflicted  with  "  snuffles,"  a  genuine  coryza  of 
the  nasal  mucous  membrane,  which  renders  respira- 
tion difficult.  The  healthy  cry  of  the  infant  is  ex- 
changed for  a  hoarse,  stridulous  noise,  due  to  the  in- 
vasion of  the  larynx  by  the  disease,  and  the  child 
sinks  rapidly  from  exhaustion  and  inanition,  or  from  a 
direct  poisoning  by  the  syphilis.  An  autopsy  reveals 
interstitial  changes  of  the  internal  organs,  especially 
in  the  liver  and  lungs,  corresponding  with  the  early 
stages  of  the  gummous  period.  Not  infrequently  the 
child,  before  death,  may  be  attacked  by  convulsions, 
due  to  inflammation  of  the  meninges  of  the  brain  or 
spinal  cord. 

If  the  symptoms  are  not  developed  until  at  or  near 


124  VENEREAL   DISEASES. 

the  sixth  month,  they  are  less  formidable  In  their 
course,  being  confined  to  manifestations  corresponding 
with  the  earlier  stages  of  acquired  syphilis.  These 
consist  of  the  erythematous  and  papulo-pustular 
eruptions  of  the  skin,  conjoined  with  the  moist  se- 
creting lesions  of  both  mucous  membrane  and  skin, 
which,  from  their  delicacy  In  Infants,  are  peculiarly 
liable  to  be  attacked.  Under  vigorous  treatment, 
the  disease  gradually  subsides,  and  the  child  passes 
through  the  earlier  years  of  its  life  with  only  occa- 
sional outbreaks,  until  the  period  of  the  second  den- 
tition arrives,  when  certain  changes  occur.  Before 
that  period,  however,  there  are  certain  peculiarities 
of  physiognomy  which  deserve  attention.  The  fore- 
head Is  very  prominent  and  bulging  ;  the  bones  of 
the  face  appear  abnormally  small,  those  of  the  nose 
are  sunken,  and  the  child  has  a  Avizened  and  aged 
appearance ;  the  angles  of  the  mouth  are  more  or 
less  deeply  scarred,  and  the  skin  has  an  unhealthy, 
sallow  look,  different  from  the  wholesome,  clean  com- 
plexion of  sound  children. 

At  the  period  of  the  second  de7ttition,  the  perma- 
nent teeth  (not  the  deciduous,  remember)  are  apt  to 
be  defective  and  bad  ;  especially  Is  this  the  case  with 
the  upper  and  lower  central  incisors.  Sometimes 
they  are  notched  at  their  cutting  edge,  and  this  may 
go  so  far  as  to  present  the  appearance  of  a  crescent ; 
at  other  times  they  stand  widely  apart,  and  the  ends 
are  bevelled  off  to  quite  a  narrow  edge,  presenting 


INFANTILE  SYPHILIS— ITS  TREATMENT      12$ 

what  are  known  as  *'  screw-driver  "  teeth.  Both  or  only 
one  of  the  incisors  may  be  thus  attacked.  The  lower 
incisors,  instead  of  being  even  and  sharp,  are  irregular, 
jagged,  and  serrated,  like  the  teeth  of  a  saw,  while  the 
other  teeth,  the  bicuspids  and  molars,  are  frequently 
black,  and  crumble  away  to  the  edge  of  the  gum. 

Together  with  these  diseases  of  the  teeth,  the  eyes 
are  liable  to  be  attacked  with  both  keratitis  and  iritis. 
Of  the  former  there  is  one  peculiar  variety,  which  is 
nearly  always  associated  with  inherited  syphilis,  and 
is  known  as  interstitial  pitnctate  keratitis.  This 
form  of  disease  begins  in  the  interstitial  layer  of  the 
cornea,  rapidly  invades  Descemet's  membrane,  and 
appears  as  numerous  minute  white  dots  scattered 
throughout  the  tissue.  Connected  with  it  there  may 
or  may  not  be  ulceration  of  the  upper  layers  of  the 
cornea.  This  form  of  disease  is  insidious  in  its  attack, 
and  is  seldom  attended  with  much  inflammation  of 
the  conjunctiva. 

Syphilitic  iritis  of  hereditary  origin  is  a  serious 
matter,  as  it  is  usually  attended  with  an  abundant 
effusion  of  lymph,  which  may  result  in  completely 
blocking  up  the  pupil  and  rendering  the  patient 
blind.  Even  if  it  do  not  go  as  far  as  this,  adhesions 
nearly  always  occur  between  the  free  edge  of  the 
pupil  and  the  anterior  capsule  of  the  lens.  The  dis- 
ease rapidly  spreads  to  the  deeper  tunics  of  the  eye, 
the  choroid  and  the  retina,  producing  serious  impair- 
ment of  vision. 


126  VENEREAL  DISEASES. 

As  the  child  advances  to  puberty,  the  bones  and 
nervous  system  begin  to  show  the  effects  of  syphiHs, 
and  the  child  will  present  enlargements  of  the  tibia 
and  ulna,  or  of  the  cranial  bones,  or  else  an  exten- 
sive ulceration  will  occur  in  the  soft  palate  and  pos- 
terior wall  of  the  pharynx.  The  nodes  of  the  bones 
often  break  down  and  suppurate,  and  at  the  bottom 
of  the  ulceration  thus  formed,  diseased  bone  will 
nearly  always  be  found. 

One  form  of  bone  lesion  occurring  in  hereditary 
syphilis  is  of  peculiar  interest.  I  refer  to  the  form 
known  as  dactylitis  syphilitica,  and  which  has  been 
well  described  by  Dr.  Taylor,  of  New  York,  in  a 
monograph  published  in  1875.  This  consists  in  an 
enlargement  of  the  phalanges  of  the  fingers  and  toes, 
generally  the  first,  which  may  increase  the  bone  to 
three  or  four  times  its  original  size.  It  is  also 
attended  with  some  degree  of  redness  and  pain.  If 
left  untreated,  this  swelling  breaks  down,  opens  in 
one  or  more  places,  and  is  frequently  associated  with 
dead  bone.  It  is  analogous  to  what  happens  in  the 
late  stages  of  acquired  syphilis,  and  may  indeed  be 
regarded  as  a  gumma  of  the  periosteum  of  the  bone. 
Under  treatment  the  swelling  subsides  to  a  crjat  de- 
gree, but  in  very  few  cases  entirely,  some  thickening 
being  left  behind  ;  and  where  the  joint  is  also  affected, 
a  stiff  and  deformed  finger  is  but  too  often  the  result. 

If  the  nervous  system  is  attacked,  the  disease 
usually  shows   itself  as   epileptiform  convulsions   or 


INFANTILE  SYPHILIS— ITS  TREATMENT      12/ 

chorea,  and  unless  the  surgeon  be  aware  of  the  possi- 
bility of  syphilis  as  the  underlying  cause,  he  is  apt  to 
regard  it  as  a  case  of  struma  or  scrofula. 

The  child,  under  proper  treatment,  may  entirely 
recover  from  these  symptoms,  but,  under  any  circum- 
stances, will  always  be  delicate  in  health,  unable  to 
withstand  the  attacks  of  intercurrent  diseases,  and 
liable  to  succumb  to  what  would  otherwise  be 
trivial  illnesses.  In  fact  they  are  rotten,  their  in- 
herited disease  continually  keeping  them  on  the 
dividing-line  between  health  and  disease.  Should 
they  be  fortunate  enough  to  reach  advanced  age, 
they  are  liable  to  ulcerations  of  the  bones  and  to 
nervous  diseases. 

With  regard  to  the  etiology  of  hereditary  syphilis, 
there  is,  even  at  the  present  day,  a  vast  difference 
of  opinion.  Many  able  writers  contend  that  the 
father  frequently  is  the  sole  cause  of  the  disease  in 
the  child,  without  the  mother  becoming  herself  in- 
fected ;  in  other  words,  they  claim  that  the  semen 
of  the  father  will  infect  the  ovum  without  conveying 
the  disease  to  the  mother.  I  avow  myself  an  abso- 
lute disbeliever  in  this  doctrine  ;  I  do  not  believe 
that  the  mother  can  give  birth  to  a  syphilitic  child 
without  being  herself  diseased  ;  and  I  hold  that  if 
the  mother  be  not  syphilitic,  the  children  are  not, 
no  matter  what  the  father  may  be.  As  in  lectures 
like  these  it  would  be  impossible  to  enter  into  a 
lengthy  discussion  of  the  pros  and  cons  of  the   case, 


128  VENEREAL  DISEASES, 

I  must  be  satisfied  to  tell  you  the  bare  fact,  and  to 
express  the  belief  that  your  future  practice  will 
confirm  my  statement.  Be  it  correct  or  not,  here 
is  the  practical  point  for  you  to  remember  when 
you  are  called  upon  to  treat  syphilitic  babies :  in- 
clude the  mother  in  the  treatment  as  well ;  the  father 
also,  if  you  can,  but  the  mother  always,  else  you 
will  be  chagrined  to  find  that  subsequent  preg- 
nancies are  followed  by  syphilitic  children. 

Syphilis,  in  its  earlier  stages,  especially  if  it  be 
of  a  mild  type,  may  show  very  few  and  slight 
symptoms,  and  even  \(  the  manifestations  attract 
notice,  the  woman,  from  notions  of  delicacy,  or  more 
frequently  from  ignorance  of  their  importance,  will 
give  the  surgeon  no  history  whatever.  Remember, 
also,  that  the  earlier  lesions  leave  no  traces  behind 
them,  and  this,  conjoined  to  the  fact  that  pregnancy 
often  exerts  an  influence  in  holding  the  earlier  mani- 
festations of  syphilis  in  check,  leaves  the  surgeon 
absolutely  in  the  dark  as  to  the  cause  of  the  child's 
syphilis.  He  then  turns  to  the  father,  and  if  the  un- 
lucky wight  has  happened  to  have  contracted  syphilis 
as  a  bachelor,  although  before  marriage  he  has  entirely 
recovered,  the  disease  of  the  child  is  laid  upon  his 
shoulders,  to  the  great  comfort  of  the  surgeon  and 
the  edification  of  all  concerned,  except,  perhaps,  the 
father.  Sometimes,  however,  he  absolutely  denies 
any  previous  disease,  and  the  case  is  then  consigned 
to  the  limbo  of  unknown  causes,  .  \ 


INFANTILE  SYPHILIS— ITS  TREATMENT.      1 29 

Syphilis  also  is  a  fruitful  cause  of  abortions  ;  and 
where,  in  any  given  case,  repeated  pregnancies  have 
ended  in  miscarriage,  it  should  always  be  regarded 
as  suspicious,  and  the  idea  of  syphilis  being  the 
cause,  entertained,  no  matter  if  the  woman  at  the 
time  shows  no  symptom  of  the  disease. 

The  treatment  in  these  cases,  to  be  of  any  avail, 
must  be  prompt  and  thorough  ;  and  here,  as  in  the 
acquired  form  of  syphilis,  mercury  is  the  main  reli- 
ance. It  is  of  little  use  to  attempt  to  treat  the  child 
through  the  mother's  milk — that  is,  by  putting  the 
mother  upon  treatment ;  because,  in  the  first  place, 
it  is  very  doubtful  if  the  mercury  is  excreted  by  the 
mammae,  and,  in  the  next  place,  if  it  be,  the  amount 
is  very  small — too  small  indeed  to  be  of  any  service. 
The  inunction  method  in  this  form  of  the  disease  is 
by  far  the  best,  and  should  be  practised  in  the 
following  manner  :  a  drachm  of  the  oleate  of  mer- 
cury (20  per  cent.)  should  be  evenly  spread  upon  a 
piece  of  cloth  or  thin  flannel  a  foot  wide,  and  long 
enough  to  go  around  the  baby's  body  ;  this  should 
be  applied  like  a  swathe,  and  the  mercury  should  be 
renewed  every  second  or  third  day.  Children  in 
this  condition  stand  mercury  remarkably  well,  and 
the  only  care  taken  should  be  to  see  that  this 
strength  of  the  ointment  does  not  irritate  the  skin  ; 
if  it  does,  a  weaker  solution  of  the  oleate  should  be 
used,  or  else  freshly  prepared  mercurial  ointment. 
In  addition,  minute  doses  of  either  the  bichloride  of 
6* 


130  VENEREAL  DISEASES. 

mercury,  or  of  gray  powder,  may  be  given  internally, 
— the  bichloride  in  doses  of  from  y^-g-  to  -g^o  of  a  grain, 
three  or  four  times  daily,  in  milk  which  has  been 
diluted  with  one-half  its  own  quantity  of  water,  and 
slightly  warmed  ;  the  gray  powder  in  3  or  5-grain 
doses,  placed  directly  upon  the  tongue.  Iodide  of 
potassium  in  these  cases  is  useless,  and  the  treat- 
ment should  be  confined  to  the  use  of  mercury  alone. 

As  regards  the  child's  nursing,  no  one  but  the 
mother  should  be  allowed  to  suckle  it,  inasmuch  as 
the  mucous  patches  which  are  nearly  always  found 
in  this  stage  of  infantile  syphilis  are  eminently  con- 
tagious, and  you  have  no  right  to  expose  an  other- 
wise healthy  woman  to  the  risk  of  infection.  It  is 
a  curious  fact,  which  was  pointed  out  as  early  as 
1837  by  Dr.  Abram  Colles,  of  DubHn,  that  the 
mothers  of  syphilitic  children,  although  they  them- 
selves may  show  no  signs  of  the  disease,  are  not 
obnoxious  to  contagion  from  syphilis  ;  hence,  the 
child  may,  with  impunity,  suckle  its  apparently 
healthy  mother,  where  it  would  be  a  source  of 
danger  to  any  healthy  stranger  who  should  attempt 
to  perform  the  maternal  function.  If  the  mother 
should  be  unable  to  suckle  the  child,  it  must  be 
weaned  and  brought  up  on  the  bottle. 

Supposing  the  child  to  recover  from  its  earlier 
symptoms — the  mercurial  treatment  having  been  con- 
tinued, of  course,  until  all  manifestations  have  disap- 
peared— it  should  be  placed  upon  a  tonic  treatment, 


INFANTILE  SYPHILIS— ITS  TREATMENT      131 

and  kept  under  observation  for  a  couple  of  years. 
It  may  then  be  dismissed,  with  the  injunction  to  the 
parents  that  fresh  symptoms  must  be  expected  when 
the  child  arrives  at  the  age  of  puberty ;  and  should 
any  manifest  themselves  either  at  that  time  or  before, 
the  child  must  at  once  be  placed  under  medical 
observation.  As  I  have  already  pointed  out  to  you, 
the  symptoms  which  present  themselves  at  the  period 
of  puberty  are  analogous  to  those  which  occur  in 
the  later  stages  of  acquired  syphilis — viz.,  nodes  of 
the  bones,  diseases  of  the  nervous  system,  and  ul- 
cerations of  the  mouth  and  throat.  Here  it  is  that 
you  find  the  iodide  of  potassium  coming  into  play 
as  a  feature  in  the  treatment,  but  noty  I  beg  you 
to  remember,  to  the  exclusion  of  mercury ;  for  you 
will  obtain  the  best  results  where  you  combine  the 
two. 

This  may  be  done  in  the  following  manner  : 

5^  •     Hydrarg.  bichlor gr.  ss.-i. 

Kali  iodidi 3  i- 

Syrup,  aurant.  cort,  or  syrup,  sars. 

comp q.  s.  ad  5  ij. 

M. 

Sig. — Teaspoonful  in  water,  three  or  four  times  daily. 

If  it  be  preferred  to  give  the  two  separately,  the 
pill  of  the  protiodide  of  mercury  may  be  given 
once  daily  in  one-quarter  or  one-third  of  a  grain  dose, 


132  VENEREAL  DISEASES. 

and  the  iodide  of  potassium  twice  or  thrice  daily,  after 
meals,  in  the  following  prescription : 

3.     Kali  iodidi 3i--3ij. 

Syrup,  sarsce  conip §  ij. 

M. 

Sig. — In  teaspoonful  doses. 

If  the  iodide  should  not  be  well  borne,  the  tincture 
of  iodine  may  be  substituted  as  follows  : 

5.     Tinct.  iod 3  ij  -iv. 

Syrupi  fusci §  iij. 

M. 

Sig. — Teaspoonful  three  times  daily. 

All  these  preparations  in  which  the  syrups  enter 
should  be  made  in  small  amounts,  and  freshly  pre- 
pared, as  the  syrup  is  liable  to  undergo  fermentation 
when  long  kept. 

In  the  intervals  of  the  mercurial  and  iodic  treat- 
ment, one  of  the  best  tonics  for  internal  administra- 
tion is  the  syrup  of  the  iodide  of  iron,  either  alone 
or  in  combination  Avith  cod-liver  oil,  and  the  syrup 
of  the  hypophosphates  of  lime  or  soda.  This  latter 
is  particularly  to  be  commended  in  the  osseous  and 
nervous  lesions  of  inherited  syphilis. 

The  following  prescriptions  will  be  of  service  : 

1^ .     Syr.  iod.  ferri |  ij . 

Sig. — Five  to  ten  minims  three  times  daily,  after  meals. 


INFANTILE  SYPHILIS— ITS  TREATMENT.      133 

"^ .     Syr.   iod.  ferri 3  iv. 

01.  morrhuae 3  iij. 

M. 

Shake  well  before  using, 

Sig. — Teaspoonful  after  meals,  thrice  daily. 

I^.     Syr.  calcis  et  sod^e  hypophosph |  ij. 

In  teaspoonful  doses  twice,  or  thrice  daily. 

This  may  be  combined  with  cod -liver  oil,  if  deemed 
desirable,  in  the  same  doses  as  given  above. 

The  old  manner  of  giving  the  iodide  of  iron  in  pill 
form — what  is  sold  under  the  name  of  Blancard's 
pill — is  not  as  good  as  the  syrup,  inasmuch  as  the 
pills,  if  kept  for  any  length  of  time,  are  apt  to  get 
hard,  and  are  not  easily  acted  upon  by  the  intestinal 
juices. 


LECTURE  X. 

GONORRHCEA  OF  BOTH   SEXES. 

GONORRHCEA,  or,  as  it  is  more  commonly  called, 
clap,  is  one  of  the  most  common  forms  of  venereal 
disease  which  you  will  be  called  upon  to  treat,  and 
oftentimes  one  of  the  most  obstinate  and  rebellious 
to  treatment.  I  shall  consider  it,  first,  as  it  affects 
the  male  ;  secondly,  as  it  affects  the  female. 

Gonorrhoea  in  the  male  is  a  muco-purulent  dis- 
charge from  the  urethra,  generally  due  to  irritation 
caused  by  a  similar  discharge  in  the  female.  This  is 
one  of  the  commonest  causes  of  the  disease  in  the 
male  ;  but  others  have  been  assigned,  and  first  among 
these  is  leucorrhoea.  This,  in  its  acute  form,  is  often 
very  difficult  to  distinguish  from  a  gonorrhoea,  inas- 
much as  they  are  both  attended  with  extreme  in- 
flammation and  redness  of  the  vaginal  membrane,  as 
well  as  with  a  profuse  purulent  yellow  discharge. 
In  addition  to  these,  the  menstrual  flow  is  regarded 
as  capable  of  inducing  a  urethral  discharge  in  the 
male  ;  and,  paradoxical  as  it  may  sound,  a  man  may 
contract  an  inflammation  and  discharge  in  these  parts 
from  a  perfectly  healthy  woman.      I  admit  that  such 


GONORRHCEA    OF  BOTH  SEXES.  135 

cases  are  very  far  from  common,  the  usual  source  of 
the  disease  being,  as  I  have  stated  above,  from  a  co- 
existent clap  in  the  female. 

Gonorrhoea  occurs  without  any  period  of  incuba- 
tion, usually  appearing  within  forty-eight  hours  after 
the  suspicious  coitus  ;  and  the  first  noticeable  symp- 
tom is  a  slight  tickhng  just  within  the  meatus,  which 
becomes  more  marked  during  micturition.  If  pres- 
sure be  exercised  along  the  floor  of  the  urethra,  a 
drop  or  two  of  sticky  fluid  can  be  squeezed  from 
the  end  of  the  penis.  This  matter  is  thin,  colorless, 
and  does  not  stain  the  linen.  After  twenty-four  to 
forty-eight  hours  have  elapsed,  the  discharge  will  be 
seen  to  lose  the  characteristics  just  detailed,  to  be- 
come thicker  and  white  like  milk  ;  and  the  act  of  mictu- 
rition is  more  painful.  If  the  disease  be  left  to  itself, 
the  discharge  becomes  more  and  more  abundant, 
sometimes  so  much  so  as  to  drip  from  the  patient ; 
it  loses  its  white  appearance  and  becomes  yellow,  and, 
if  the  inflammation  is  acute,  of  a  greenish  or  rusty 
hue,  from  the  admixture  of  blood.  The  act  of  uri- 
nation now  becomes  decidedly  painful,  the  stream  of 
water  very  much  diminished  in  size,  and  when  the 
inflammation  is  high  the  water  is  only  passed  drop 
by  drop.  Where  this  condition  of  things  obtains, 
febrile  symptoms  are  often  present,  particularly  in  a 
first  attack,  attended  with  a  high  pulse,  hot  and  dry 
skin,  and  a  furred  tongue.^  The  penis  is  oedematous 
and    swollen,  and  where    the    prepuce    is   long    the 


13^  .  VENEREAL  DISEASES. 

oedema  may  be  so  great  as  even  to  cause  partial  or 
complete  phimosis.  The  lymphatics  on  the  dorsum 
penis  are  enlarged,  red,  and  painful,  and  the  glands 
in  the  groin  may  also  participate  in  the  general  in- 
flammation—  becoming,  in  their  turn,  swollen  and 
tender. 

In  other  cases,  the  inflammatory  symptoms  may 
be  entirely  absent,  the  only  signs  present  being  pain- 
ful micturition  and  a  purulent  discharge.  This 
usually  reaches  its  height  about  the  tenth  day,  invad- 
ing in  its  progress  the  urethral  mucous  membrane 
from  the  fossa  navicularis,  the  starting-point  of  the 
disease,  to  the  region  of  the  bulbus  urethrae.  At 
this  date  the  discharge  retains  its  yellow  character, 
but  the  act  of  micturition  is  less  painful  than  during 
the  first  few  days  of  the  clap.  It  then  remains  sta- 
tionary for  another  ten  days  or  so,  when  the  discharge 
gradually  loses  its  purulent  and  yellow  character, 
changing  to  white,  and  from  that  to  a  thin,  viscid, 
colorless  flow,  running,  in  other  words,  but  in  a  de- 
scending scale,  through  the  same  course  that  it  pur- 
sued in  its  commencement.  As  the  discharge  be- 
comes less  and  less  purulent,  the  act  of  micturition 
becomes  easier,  until  finally  all  pain  and  discomfort 
cease  during  the  act.  Gradually  this  thin  discharge 
diminishes,  until  it  finally  dries  up  entirely,  and  the 
patient  finds  himself  well.  This  is  the  course  usually 
pursued  where  no  complications  are  present ;  where 
these  occur,  however,  the  duration  of  the  disease  is 


GONORRHCEA    OF  BOTH  SEXES.         -    137 

much  more  prolonged,  more  painful  and  serious,  but 
of  these  I  shall  speak  in  a  separate  lecture. 

In  the  female,  the  disease  shows  itself  first  as  an 
inflammation  of  the  vulvar  mucous  membrane,  in- 
vading the  vestibule  and  the  labia  majora  et  minora. 
Micturition  is  attended  with  some  smarting  and  pain, 
due  to  the  acid  urine  passing  over  the  irritated  and 
inflamed  mucous  membrane,  and  not  to  any  disease 
of  the  urethra  itself.  Where  you  find  the  urethra  in 
women  the  seat  of  a  muco-purulent  discharge,  you 
may  say  with  confidence  that  the  disease  is  gonor- 
rhoea, for  no  leucorrhcea  that  I  am  conversant  with 
is  attended  with  a  discharge  from  the  urethra.  At- 
tendant upon  this  inflammation  of  the  mucous  mem- 
brane of  the  vulva,  is  a  thin,  viscid,  colorless  dis- 
charge, analogous  to  what  occurs  in  the  male,  which 
speedily  becomes  thick,  abundant,  and  purulent, 
staining  the  woman's  body-linen.  This  inflammation 
rapidly  extends  from  the  vulva  along  the  vagina, 
which  upon  examination  is  seen  to  be  red,  swollen, 
and  secreting  an  abundant  amount  of  thick,  yellowish 
pus.  The  temperature  of  the  parts  is  also  increased. 
This  inflammation  may  extend  to  the  mucous  mem- 
brane lining  the  cervix  uteri,  and  even  to  the  uterus 
itself,  producing  serious  symptoms.  After  lasting  for 
several  weeks,  the  discharge  diminishes  in  intensity 
and  purulence,  and  the  mucous  membrane  of  the 
vagina  becomes  less  red  and  swollen,  although  the 
discharge  may   continue  for  some   time    longer.     It 


138  VENEREAL  DISEASES. 

now,  however,  becomes  of  a  light  yellow  or  white 
color,  closely  resembling  an  ordinary  leucorrhoeal 
discharge.  When  it  arrives  at  this  stage,  unless  sub- 
jected to  treatment,  it  remains  stationary  for  a  long 
time,  being  liable  to  exacerbation  from  various  causes, 
until  it  gradually  wears  away  to  the  thin,  viscid  dis- 
charge which  marked  the  advent  of  the  disease. 
Pain  is  no  longer  felt  during  micturition,  as  the  mu- 
cous membrane  of  the  vulva  becomes  thickened,  and 
is  no  longer  sensitive. 

As  regards  the  etiology  of  this  disease,  I  wish  to 
explain  to  you  a  little  more  fully  what  I  told  you  in 
the  beginning  of  this  lecture.  It  is  easy  to  under- 
stand how  a  clap  in  a  woman  may  produce  the  same 
in  the  male ;  but  why  the  menstrual  flow,  or  why  a 
perfectly  healthy  woman  should  be  capable  of  excit- 
ing trouble  in  the  male,  is  not  quite  so  easy  to  com- 
prehend. In  the  first  place,  you  must  distinctly 
bear  in  mind  that  gonorrhoea  is  not  produced  by  any 
virus,  such  as  we  understand  the  term  when  speak- 
ing of  chancroid  and  syphilis  ;  it  is  a  pure  and  simple 
catarrhal  inflammation,  and  may  be  produced  arti- 
ficially in  a  healthy  person,  by  the  use  of  irritating 
injections,  and  even  by  the  improper  use  of  sounds. 
If  now  a  man  has  connection  with  a  woman  during 
the  menstrual  period,  more  particularly  at  its  com- 
mencement, or  toward  its  close,  this  flow,  from  its 
irritating  nature,  may  sometimes  produce  an  inflam- 
mation  of  the  urethral    mucous    membrane    in   the 


GONORRHCEA    OF  BOTH  SEXES.  1 39 

male.  I  confess  to  some  degree  of  scepticism  in 
cases  alleged  to  be  produced  from  this  cause,  but  as 
it  is  reckoned  among  the  possibilities,  I  give  it  to 
you  here  for  what  it  is  worth. 

The  causes  which  produce  clap  from  connection 
with  a  healthy  woman  are  due  much  more  to  the 
man  than  to  the  woman.  In  your  future  practice, 
you  will  often  be  told  some  story  like  the  following  : 
The  man,  after  dining  with  a  party  of  friends,  and 
having  drunk  freely  at  dinner,  has  intercourse  with  a 
woman  of  the  town.  Afraid  of  the  consequences, 
and  desirous  of  averting  them  as  far  as  possible,  he 
borrows  a  favorite  clap  prescription  from  some  friend, 
and  injects  it  industriously  into  his  urethra,  when, 
after  the  lapse  of  a  few  days,  he  is  much  disgusted  to 
find  the  very  disease  appearing  which  he  fondly 
hoped  he  had  averted  ;  in  other  words,  he  has  given 
himself  a  clap  from  his  officious  over-medication.  The 
woman  is  examined,  and  the  parts  are  found  healthy, 
nor  is  there  any  reason  to  believe  that  she  was  the 
cause  of  the  trouble  in  her  companion.  To  speak 
strictly,  the  woman  has  had  nothing  at  all  to  do  with 
inducing  the  disease  ;  it  has  been  entirely  the  man's 
fault. 

Besides  these  causes,  Ricord  has  stated  that  sexual 
excitement,  without  contact  or  any  other  kind  of 
irritation,  might  produce  a  urethral  discharge  in  the 
male,  and  he  gives  one  case  which  stands  unique  in 
venereal  literature.     It  occurred  in  the  person  of  a 


140  VENEREAL  DISEASES. 

physician,  who,  from  ten  o'clock  in  the  morning  until 
seven  in  the  evening,  vainly  endeavored  to  overcome 
the  virtuous  scruples  of  a  young  woman  with  whom 
he  was  in  love,  and  during  all  this  time  he  was  in  a 
condition  of  extreme  sexual  excitement.  Three  days 
afterward  he  was  attacked  with  a  most  painful  and 
violent  clap,  which  lasted  for  forty  days.  Let  me 
add  that  previous  to  this  unlucky  tete-a-tete,  it  is 
stated  that  the  physician  had  been  continent  for  six 
weeks.  I  candidly  admit  that  I  do  not  believe  the 
story.  I  think  that  Ricord  was  willing  to  be  chari- 
table to  a  brother  physician  ;  and  had  it  occurred  in 
the  person  of  any  but  a  confrere,  he  would  have  made 
it  the  subject  of  ridicule.  At  any  rate,  no  similar 
cases  have  ever  been  reported  to  my  knowledge. 

Let  me  tabulate  the  following  axioms  for  you  : 

GonorrJicea  does  not  depend  upon  a  vims ;  it  is  a 
simple  catarrh  of  the  urethral  mucous  membrane^  and 
is  due  to  the  presentee ^  within  the  canal,  of  some  local 
irritant.  Gonorrhoea  is  produced  bygonorrhceal^  leu- 
corrhoeal  and  tJie  menstrual  discharges. 

A  perfectly  healthy  womaji  is  reputed  to  be  capable 
of  producing  urethral  inflammatio7i  in  tJie  male  ;  such 
cases,  hozvevery  should  not  be  admitted  without  some 
reserve. 

Gonorrhoea  has  no  pei'iod  of  incubation. 

You  would  be  wrong  should  you  consider  that 
every  urethral  discharge  in  the  male  is  necessarily  a 
clap  ;  undoubtedly  the  majority  of  such  diseases  are 


GONORRHCEA    OF  BOTH  SEXES.  I4I 

gonorrhoeal,  but  you  may  also  have  other  causes  at 
work  to  produce  this  condition  of  things.  A  urethral 
chancroid  or  initial  lesion  will  produce  a  running  from 
the  genitals,  and  it  is  oftentimes  difficult  to  decide  at 
once  whether  the  disease  under  observation  is  really 
a  simple  clap  or  not.  If  the  cause  be  due  to  a  con- 
cealed chancroid  the  following  symptoms  will  serve 
to  put  you  upon  the  right  track.  The  pain  in  the 
urethra  is  localized,  and  not  general  as  it  is  in  clap  ; 
the  discharge,  although  purulent,  is  not  very  abun- 
dant, and  is  frequently  streaked  with  fresh  blood,  and 
pressure  along  the  floor  of  the  urethra  excites  pain 
only  at  the  seat  of  the  lesion.  The  crucial  test,  how- 
ever, is  auto-inoculation.  If  the  matter  be  due  to 
chancroid  it  is  capable,  by  inoculation,  of  producing 
another  chancroid,  while  gonorrhoeal  pus  is  innocuous. 
Separation  of  the  lips  of  the  urethra  will  often  dis- 
cover the  sore  seated  just  within  the  meatus  ;  but  if, 
as  sometimes  happens,  it  is  situated  deeper  within 
the  canal,  the  examination  must  be  conducted  in 
another  manner.  An  instrument  called  the  meato- 
scope  should  be  passed  a  short  distance  into  the 
urethra  as  far  as  the  fossa  navicularis,  and  a  strong 
light  thrown  into  the  canal  with  a  reflecting  mirror, 
when  the  lesion  will  be  brought  clearly  and  plainly 
into  view.  An  ordinary  ear  speculum,  by  the  way, 
makes  one  of  the  best  instruments  for  examination — 
better,  indeed,  than  nine-tenths  of  the  meatoscopes 
offered  for  sale  in  the  shops. 


142.  VENEREAL  DISEASES, 

If,  however,  the  discharge  be  due  to  a  concealed 
initial  lesion,  the  symptoms  are  somewhat  different  ; 
the  discharge  is  very  thin,  and  seldom  becomes  pu- 
rulent, unless  irritated  from  some  cause  or  another. 
Palpation  reveals,  in  the  great  majority  of  cases,  an 
indurated  spot  in  the  course  of  the  canal,  and  an  ex- 
amination of  the  urethra  in  the  method  already  ad- 
vised gives  the  clew  to  the  proper  source  of  the 
urethral  discharge. 

Besides  these  causes,  gouty  persons  are  very  liable 
to  slight  discharges  from  the  urethra  ;  and  especially 
is  this  the  case  after  the  patients  have  indulged  a 
little  more  freely  than  usual  in  the  pleasures  of  the 
table,  particularly  in  the  use  of  heavy- bodied  wines, 
such  as  Burgundy  or  port.  Here  the  disease  comes 
on  without  any  history  of  sexual  indulgence,  and  is 
attended  with  pain  during  micturition  near  the  neck 
of  the  bladder  and  along  the  course  of  the  prostatic 
urethra.  The  discharge  which  accompanies  this  form 
of  disease  is  not  very  abundant,  although  it  is  slightly 
purulent ;  it  stains  the  patient's  linen,  and  comes 
from  the  deeper  part  of  the  canal — never  from  the 
anterior  portion,  as  in  clap.  The  urine  is  very  acid, 
and  loaded  with  urates.  Under  proper  treatment, 
these  symptoms  abate  in  the  course  of  a  week,  and 
leave  the  patient  as  well  as  he  was  before. 

Tight  strictures  of  the  deep  urethra  may  also  cause 
a  muco-purulent  discharge  ;  but  as  a  consideration  of 
these  diseases  belongs   rather  to  the  domain  of  sur- 


GONORRHCEA    OF  BOTH  SEXES.  143 

gery  than  of  venereal  medicine,  I  shall  content  my- 
self with  a  mere  mention  of  them  as  an  exciting 
cause. 

The  duration  of  a  clap  varies  very  much.  As  I 
have  already  told  you,  in  the  female  it  may  last  for 
several  weeks,  and  even  months,  and  is  one  of  the 
most  obstinate  diseases  to  treat,  owing  to  its  liability 
to  invade  the  mucous  membrane  of  the  cervix  uteri, 
where  it  is  difficult  to  reach  it  by  local  remedies,  and 
internal  treatment  has  but  little  if  any  efficacy  in 
vaginal  and  cervical  gonorrhoea. 

In  the  male,  however,  although  sufficiently  obsti- 
nate, it  is  not  so  chronic  as  in  the  female  ;  and  this  is 
due,  in  a  great  measure,  to  the  greater  care  and  per- 
sistency with  which  the  treatment  is  followed  up.  In 
man  the  disease,  unless  complicated,  usually  runs  its 
course  in  from  four  to  six  weeks  ;  but  if  any  of  the 
complications  supervene  of  which  I  shall  speak  to 
you  in  the  next  lecture,  the  disease  may  be  prolonged 
for  eight,  ten,  or  more  weeks.  Much  depends  upon  the 
attention  and  fidelity  with  which  the  patient  carries 
out  the  treatment,  and  he  should  be  particularly  cau- 
tioned to  continue  it  for  a  short  time  after  apparent 
recovery  has  taken  place,  because  a  clap  is  very 
prone  to  relapse,  and  each  relapse  makes  the  disease 
more  difficult  to  cure. 


LECTURE  XI. 

COMPLICATIONS   WHICH  OCCUR  IN  GONORRHCEA. 

The  complications  which  occur  in  gonorrhoea  are 
numerous,  and  some  of  them  quite  serious  in  their 
nature.  The  first  one  which  I  shall  consider  is 
balanitis,  or  an  inflammation  of  the  mucous  mem- 
brane of  the  prepuce  and  the  glans  penis,  which  is 
characterized  by  intense  redness  of  these  parts,  and 
is  attended  with  superficial  excoriations,  which  may 
be  easily  mistaken  for  superficial  chancroids,  or  for 
mucous  patches  ;  but  the  inability  to  inoculate  their 
secretion,  their  superficial  character,  and  the  facility 
with  which  they  get  well  under  the  simplest  treat- 
ment, will  prevent  their  being  mistaken  for  the  for- 
mer ;  and  the  absence  of  concomitant  symptoms,  as 
well  as  all  history  of  syphilis,  will  exclude  them  from 
the  category  of  syphilitic  manifestations.  They 
usually  appear  as  mere  drosions  of  mucous  membrane, 
and  seldom,  unless  irritated,  are  they  covered  over 
with  any  secretion.  If  a  pellicle  form  over  the 
abraded  points,  it  can  usually  be  readily  removed. 

Phimosis  and  para-pJiimosis  may  occur  in   those 
cases  where  the  inflammation  is  very  acute,  and  some- 


COMPLICATIONS  IN  GONORRHCEA.         145 

times  go  so  far  as  to  produce  serious  inconvenience 
and  even  danger.  In  phimosis,  the  prepuce  is  in- 
capable of  retraction,  and  the  discharge  from  the 
urethra  as  well  as  the  urine  collects  within  the  con- 
stricted foreskin,  requiring  the  utmost  attention  on 
the  part  of  the  patient  to  cleanliness,  in  order  to  ob- 
viate ulceration  and  sloughing  of  the  prepuce. 

Where  the  prepuce  is  naturally  short,  if  the  parts 
become  inflamed  and  swollen  the  constriction  takes 
place  behind  the  glans  penis  at  the  fossa  glandis, 
and,  unless  relieved,  may  go  on  to  gangrene  and 
sloughing  of  the  glands.  This  portion  of  the  penis 
becomes  purple,  the  temperature  is  diminished,  and 
the  parts  slough  from  the  mechanical  obstruction  to 
the  circulation. 

Sometimes  along  the  course  of  the  urethra  one  or 
more  points  m.ay  become  hard  and  exquisitely  ten- 
der, which,  after  a  time,  soften  and  break  down,  dis- 
charging a  quantity  of  laudable  pus.  These  are 
known  as  peri-urethral  abscesses,  and  are  usually 
found  at  the  frenum,  the  peno-scrotal  angle,  and  the 
perineum,  although  they  sometimes  occur  at  inter- 
mediate points.  They  are  usually  ushered  in  with  a 
chill  and  a  slight  rise  in  temperature,  which  is  speed- 
ily followed  by  the  presence  of  pus  in  the  swelling. 
Attaining  to  large  size,  they  often  press  upon  the 
urethra  in  such  a  way  as  to  diminish  its  calibre  and 
interfere  seriously  with  the  act  of  micturition. 

One  of  the  most  frequent  complications  of  gonor- 
7 


146  VENEREAL  DISEASES. 

rhoea  in  the  male  is  known  as  chordee,  which  is  a 
painful  curvature  of  the  penis  during  erection.  This 
may  take  place  in  three  ways  :  with  the  concavity 
looking  downwards,  upwards,  or  sideways,  and  is  due 
to  an  exudation  of  lymph  into  the  corpus  spongi- 
osum or  the  corpora  cavernosa.  This  distressing 
symptom  comes  on  only  during  erection,  and  seems 
to  be  particularly  favored  by  the  heat  and  warmth  of 
the  bed.  Sometimes  the  amount  of  inflammation 
and  distortion  which  occurs  is  so  great  as  to  produce 
free  hemorrhage  from  the  urethra,  leading  to  tempo- 
rary relief,  but  as  soon  as  the  local  effect  has  passed 
off,  the  chordee  returns  as  vigorously  as  ever. 

After  a  clap  has  lasted  for  three  or  four  weeks,  in- 
vading the  deeper  portion  of  the  urethra,  the  patient 
begins  to  complain  of  uneasiness  and  pain  in  the  tes- 
ticles, and,  upon  examination,  these  organs  are  found 
to  be  enlarged  and  tender.  Although  the  name  of  or- 
chitis has  been  given  to  this  affection,  the  body  of  the 
testicle  itself  is  not  implicated,  but  only  the  epididy- 
mis, which  in  this  stage  of  the  disease  is  attended  by 
the  usual  symptoms  of  pain,  redness,  and  swelling. 
You  remember,  when  we  were  discussing  syphilis,  I 
mentioned  a  form  of  epididymitis  which  occurs  in 
that  disease,  and  I  wish  to  call  your  attention  to  the 
diagnostic  points  of  difference  which  obtain  between 
the  two  varieties.  In  syphilitic  epididymitis  this 
body  is  indurated,  but  is  devoid  of  pain  or  redness, 
indeed,  so  little  uneasiness  is  there,  that  the  part  can 


COMPLICATIONS  IN  GONORRHCEA.         147 

be  freely  handled  without  inconvenience  to  the  pa- 
tient, but  in  the  gonorrhceal  variety  the  epididymis  is 
red,  swollen,  and  exquisitely  tender,  so  much  so  that 
the  mere  contact  of  the  bed-clothes  is  sufficient  to 
excite  pain  and  discomfort,  and  I  need  hardly  add 
that  free  handling  of  the  part  is  impossible.  This 
generally  comes  on  about  the  third  or  fourth  week 
of  the  duration  of  the  clap,  and  during  its  continu- 
ance the  urethral  discharge  almost  entirely  disap- 
pears— to  reappear,  however,  upon  its  subsidence. 

The  acute  inflammation  lasts  from  seven  to  ten 
days,  at  the  expiration  of  which  time  it  gradually 
subsides,  leaving  the  epididymis  indurated,  although 
not  very  sensitive,  and  this  induration  may  be  further 
complicated  by  the  effusion  of  fluid  between  the  two 
layers  of  the  tunica  vaginalis,  constituting  what  is 
known  as  hydrocele.  Under  proper  treatment  the 
fluid  is  absorbed,  and  the  swelling  of  the  epididymis 
diminishes;  indeed,  under  very  favorable  circum- 
stances, it  may  entirely  disappear  ;  but  this  result  is 
not  always  attained.  Only  too  often  the  epididy- 
mis, as  well  as  the  vas  deferens,  is  permanently 
blocked  up,  preventing  the  egress  of  the  sperma- 
tozoa from  the  affected  testis,  and  leading  to  partial 
sterility.  Instead  of  resolution,  one  other  course  may 
be  pursued  :  the  part  may  suppurate  ;  and  when  it 
does,  destruction  of  the  epididymis,  and  sometimes 
of  the  testicle  on  that  side,  follows. 

The  disease  is  usually  unilateral,  one  testis  being 


148  VENEREAL  DISEASES. 

affected  pretty  nearly  as  often  as  the  other  ;  but  some- 
times it  is  double,  when,  of  course,  it  becomes  more 
serious,  inasmuch  as  the  induration  and  obliteration 
of  the  canals  of  the  vasa  deferentia  lead  to  permanent 
sterility.  I  beg  you  will  distinctly  understand  the  dif- 
ference between  sterility  and  impotence  ;  the  sterile 
patient  is  not  rendered  impotent,  he  is  capable  of  per- 
fect connection  even  to  the  emission,  but  the  semen 
ejected  is  devoid  of  spermatozoa — in  other  words,  he 
is  incapable  of  procreation  ;  while  the  impotent  man 
is  incapable  of  connection,  although  his  semen  is 
fruitful.  When  one  testis  only  is  affected,  the  pa- 
tient can  still  be  the  father  of  children,  but  only  as 
regards  his  sound  testicle. 

The  inflammation  may  extend  from  the  testis  to 
the  spermatic  cord,  and  when  this  is  the  case  the 
patient  complains  of  pain  running  from  the  testis  to 
the  lumbar  region,  with  a  dragging  sensation  upon 
the  cord,  as  though  traction  were  being  exercised 
upon  it.  An  examination  reveals  a  thickened  condi- 
tion of  this  portion  of  the  genital  apparatus,  which  is 
sometimes  enlarged  to  the  size  of  a  goose-quill,  and 
excessive  tenderness,  with  inflammatory  redness  run- 
ning up  as  far  as  the  ring.  Treatment  usually  causes 
these  acute  symptoms  to  abate  in  from  five  to  ten 
days ;  the  thickening,  however,  lasts  longer,  until 
finally  it  entirely  disappears,  and  the  cord  resumes 
its  normal  condition. 

In  rare  instances  resolution  does  not  take  place; 


COMPLICATIONS  IN  GONORRHCEA,         149 

but  instead  of  this,  suppuration  occurs  somewhere 
along  the  course  of  the  cord  external  to  the  ring. 
When  this  takes  place,  there  is  danger  of  atrophy  of 
the  testis,  resulting  from  obliteration  of  the  spermatic 
vessels. 

Later  in  the  disease  other  portions  of  the  genito- 
urinary apparatus  may  be  affected,  and  the  prostate 
is  the  next  organ  to  feel  its  effects.  This  body  is,  as 
you  know,  composed  of  both  muscular  and  glandular 
tissue,  and  encircles  the  neck  of  the  bladder ;  and 
from  the  intimate  connection  between  the  two,  one 
rarely  escapes  when  the  other  is  attacked.  Hence,  I 
shall  consider  the  two  together,  although  they  are  often 
treated  in  works  on  Venereal  Diseases  under  the  sepa- 
rate heads  oi prostatitis  and  cystitis.  The  first  symp- 
tom which  the  patient  notices  is  a  sensation  of  uneasi- 
ness rather  than  of  actual  pain  in  the  perineum,  to- 
gether with  a  feeling  of  weight  and  tension  in  the  part, 
and  this  is  particularly  noticeable  when  he  sits  down. 
This  symptom  gradually  increases  until  both  the  erect 
and  sitting  posture  is  painful,  and  the  patient  only 
fmds  relief  when  lying  upon  his  back.  Connected 
with  this  is  a  still  more  unpleasant  symptom,  viz.,  a 
constant  and  urgent  desire  to  pass  water,  which 
comes  upon  the  patient  so  suddenly  and  violently 
that,  no  matter  where  he  is,  he  has  to  respond  at  once 
to  this  call  of  nature,  and  the  urine  is  voided  quite  as 
frequently  in  his  clothing  as  out  of  it.  After  the 
water  is  ejected — and  nearly  always  this  occurs  in 


ISO  VENEREAL  DISEASES, 

very  small  quantities — there  is  a  violent  straining  and 
bearing  down,  which  is  present  not  only  at  the  neck 
of  the  bladder,  but  in  the  rectum  as  well,  as  though 
the  bladder  and  rectum  needed  instant  evacuation. 
This  is  known  as  tenesmus,  and  may  be  so  violent  as 
to  cause  haemorrhoids  or  a  prolapse  of  the  bowel. 

Upon  examination  through  the  rectum,  the  pros- 
tate will  be  found  enormously  enlarged,  encroaching 
upon  the  bowel,  and  most  exquisitely  tender,  and 
this  inflammation  may  pursue  one  of  two  courses  : 
either  the  symptoms  entirely  subside  and  the  disease 
passes  off,  or  an  abscess  of  the  prostate  may  result. 
If  this  occur,  it  terminates  either  by  breaking  into 
the  urethra — the  most  favorable  of  all  courses — or  else 
it  opens  into  the  rectum,  producing  a  recto-prostatic 
abscess ;  or  if,  as  sometimes  happens,  the  abscess 
opens  in  both  directions,  a  fistula  between  the  urethra 
and  rectum  is  established,  which  is  extremely  diffi- 
cult to  cure. 

Another  complication  is  what  is  known  as  cowperi- 
tis ;  an  inflammation  of  two  little  glands  seated  ante- 
rior to  the  prostate,  the  ducts  of  which  open  into  the 
urethra.  Sometimes  this  occurs  alone,  but  it  is  more 
frequently  associated  with  prostatitis.  The  symp- 
toms in  the  two  diseases  are  much  the  same,  and  the 
course  they  pursue  is  very  similar. 

The  vesiculae  seminales  are  also  liable  to  be  at- 
tacked, when  the  patient  will  complain  of  deep-seated 
pain  in  the  perineum,  usually  upon  one  side.     An 


COMPLICATIONS  IN  GONORRHOEA.  151 

examination  per  rectum,  carrying  the  finger  well  up 
alongside  of  the  bladder,  reveals  a  tender  and  swollen 
spot,  which  after  a  time  gradually  subsides,  or  else 
it  ends  in  suppuration. 

To\vard  the  end  of  a  clap,  when  the  discharge  has 
become  thin  and  colorless,  when  the  anterior  portion 
has  entirely  recovered  its  normal  condition  while 
the  posterior  portion  of  the  urethra  still  remains  dis- 
eased, a  condition  of  affairs  arises  to  which  the  name 
oi gleet  has  been  given.  Here  the  discharge,  instead 
of  being  continuous  as  it  is  during  a  clap,  is  only 
seen  on  rising  in  the  morning  as  a  single  drop  of 
white  or  colorless  matter,  which  does  not  stain  the 
linen,  and  which  is  not  accompanied  with  any  pain 
during  micturition.  This  drop  of  fluid  is  usually  ob- 
tained only  upon  deep  pressure,  and  during  the  day 
is  absent.  If  the  patient  commits  any  excess  in  eat- 
ing or  drinking,  or  if  he  indulge  in  immoderate 
coitus,  this  drop  may  increase  to  a  slightly  purulent 
discharge,  which  lasts  for  a  few  days,  and  then  sub- 
sides to  its  former  condition.  Examination  with  a 
bulbous  bougie  will  reveal  in  the  membranous  or 
prostatic  portions  of  the  urethra  one  or  more  local- 
ized points  of  tenderness,  which  offer  a  slight  resist- 
ance to  the  passage  of  the  bougie,  and  which  usually 
bleed.  This  is  due  either  to  a  granular  and  thickened 
condition  of  the  urethra,  the  incipient  stage  of  stric- 
ture, or  else  to  a  slight  stricture  which  has  already 
formed.     Remember,  that  nine  cases  in  ten  of  gleet 


152  VENEREAL   DISEASES. 

are  dependent  upon  stricture ;  hence,  when  called 
upon  to  treat  a  gleet,  always  search  at  once  for  stric- 
ture, and  generally  the  removal  of  that  means  the 
cure  of  the  gleet.  If  no  stricture  be  found,  then  the 
discharge  is  due  to  inflammation  of  the  deep  urethra, 
attended  perhaps  by  slight  erosions  of  the  mucous 
membrane,  which  will  require  different  treatment  to 
what  it  would  were  it  due  to  a  stricture. 

I  have  purposely  omitted  speaking  at  length  on 
stricture,  as  this  form  of  disease  belongs  more  prop- 
erly to  the  domain  of  genito-urinary  surgery  than  to 
venereal  medicine;  and  I  only  mention  it  here  to  show 
you  how  it  may  act  as  one  of  the  underlying  causes 
of  gleet. 

In  the  female  the  complications  which  occur  in  the 
course  of  a  clap  are  not  so  numerous,  but  at  the  same 
time  some  of  them  are  much  more  serious.  One  of 
the  most  frequent  is  that  which  occurs  in  the  earlier 
stage  "of  the  disease  known  as  vulvitis j  and  is  anal- 
ogous to  balanitis  in  the  male.  It  is  attended  with 
erosions  of  the  mucous  membrane  of  the  vulva,  the 
vestibule,  and  the  fourchette,  with  a  copious  muco- 
purulent discharge,  which,  flowing  over  the  perineum 
and  the  inside  of  the  thighs,  irritates  and  excoriates 
these  parts.  If  the  inflammation  is  very  acute,  the 
labia  majora  become  cedematous  and  swollen,  and 
sometimes  it  ends  in  suppuration.  In  addition  to 
this  the  gland,  which  is  known  as  the  vulvo-vaginal, 
or  gland  of  Bartholin,  the  duct  of  which  opens  just 


COMPLICATIONS  IN  GONORRHOEA.  153 

within  the  introitus  vaginae,  becomes  enlarged  and 
painful.  This  may  be  felt  as  an  ovoid  swelling  seated 
at  the  posterior  commissure  of  the  labia,  is  usually 
unilateral  and  nearly  always  ends  in  suppuration,  fol- 
lowing one  of  two  courses,  the  pus  either  being 
evacuated  through  the  duct  into  the  vagina,  or,  if  oc- 
clusion of  the  duct  ensue,  requiring  an  incision  ex- 
ternally for  its  cure. 

Although  gonorrhoea  in  women  is  generally  con- 
fined to  the  vulva  and  vagina,  it  sometimes  happens 
that  the  urethra,  as  in  the  male,  is  the  seat  of 
trouble,  either  concomitant  with  the  vaginitis,  or 
else,  very  rarely,  alone.  Owing  to  this  canal  being 
shorter  in  the  female  than  in  the  male,  urethritis  in 
women  produces  but  Httle  disturbance  beyond  an 
urgent  desire  for  frequent  urination,  and  is  seldom 
followed  by  cystitis.  To  detect  its  presence,  the 
vagina  being  first  thoroughly  cleansed  of  ail  dis- 
charge, the  surgeon  passes  his  finger  into  this  canal 
and  makes  firm  pressure  along  the  urethra  from 
the  neck  of  the  bladder  downward  and  outward 
toward  the  meatus,  when  a  few  drops  of  pus  follow 
the  finger.  When  you  find  this  condition  of  things 
you  may  be  sure  you  have  to  deal  with  a  gonor- 
rhoea (of  course  supposing  there  is  no  concealed 
urethral  chancroid  or  initial  lesion),  for  no  other 
disease  that  I  am  aware  of  produces  similar  symp- 
toms. If  there  be  a  concealed  urethral  ulceration, 
the  symptoms  will  be  the  same  as  those  detailed  a 


154  VENEREAL  DISEASES. 

few  pages  back,  when  speaking  of  similar  lesions  in 
the  male. 

You  may,  therefore,  formulate  the  following  rule : 

Urethritis  in  the  female  is  always  due  to  some 
venereal  affection. 

I  have  already  sketched  the  course  which  a  gonor- 
rhoeal  vaginitis  pursues  in  an  ordinary  case,  and  have 
shown  how  it  spreads  from  the  anterior  portions  to 
the  deeper  parts,  ending  in  an  inflammation  and  puru- 
lent discharge  from  the  cervix.  But  it  may  extend 
even  beyond  this  region,  and,  invading  the  body  of 
the  uterus  itself,  extend  along  the  Fallopian  tubes 
and  attack  the  ovaries.  This  inflammation  of  the 
uterus,  or,  as  it  is  called,  metritis,  is  always  a  serious 
matter,  and  commences  with  a  feeling  of  congestion 
of  the  organ,  attended  by  a  severe  bearing-down  pain 
and  disturbance  of  menstruation,  which  is  usually 
scanty  and  difficult.  If  a  recto-vaginal  examination 
be  made,  the  organ  will  be  found  swollen  and  ex- 
quisitely tender,  and  pressure  above  the  pubes  excites 
similar  discomfort.  High  fever,  increase  in  tempera- 
ture, and  a  full  pulse  are  nearly  always  present.  As 
the  disease  passes  along  the  Fallopian  tubes  symp- 
toms of  peritonitis  present  themselves,  which  may 
increase  in  intensity  and  result  fatally.  This  termina- 
tion is  not  a  common  one,  although  a  few  cases  have 
been  reported  ;   it  usually  ends  in  recovery. 

When  the  ovaries  are  attacked  pain  is  experienced 
over  the  region  of  one  or  the  other  of  these  bodies, 


COMPLICATIONS  IN  GONORRHCEA.  1 55 

which  is  intensified  upon  deep  pressure  externally  or 
upon  a  vaginal  examination.  The  skin  covering  the  ova- 
rian region  shows  signs  of  inflammation,  and  this  form 
of  disease  is  frequently  attended  with  febrile  manifesta- 
tions, which  after  lasting  a  week  or  ten  days,  gradually 
subside  and  the  parts  resume  their  former  condition. 

Besides  these  symptoms,  if  the  inflammation  be 
very  acute,  the  lymphatics  and  the  inguinal  glands  in 
both  sexes  are  implicated.  In  the  male,  the  lym- 
phatics running  along  the  dorsum  of  the  penis  may 
be  felt  as  a  hard  line,  the  size  of  a  large  goose-quill, 
running  from  the  fossa  glandis  to  the  crura  penis,  and 
are  there  lost  in  the  inguinal  chain  of  glands.  Their 
course  may  often  be  followed  by  the  eye,  appearing 
as  a  broad,  red  line  overlying  the  inflamed  lym- 
phatics. After  a  while  the  inflammation  subsides  and 
the  lymphatics  are  no  longer  apparent  to  the  eye  or 
to  the  finger,  or  else  suppuration  occurs  at  one  or 
more  points  along  their  track,  which,  upon  evacua- 
tion of  the  pus,  usually  heal  readily. 

This  inflammation  may  extend  to  the  inguinal 
glands  when  we  have  in  one  or  both  groins  a  tense, 
brawny,  and  inflamed  swelling,  painful  to  the  touch, 
and  a  hinderance  to  locomotion.  This  enlargement 
may  be  ushered  in  with  a  chill  and  a  slight  elevation 
in  the  temperature.  Sometimes  the  inflammation 
subsides  without  ending  in  suppuration,  while  again 
pus  forms  within  the  body  of  the  gland  and  an  ab- 
scess is  the  result. 


15^  VENEREAL  DISEASES. 

Two  other  forms  of  disease  resulting  from  gonor- 
rhoea yet  remain  to  be  spoken  of — to-wit,  rheuma- 
tism and  ophthalmia.  The  occurrence  of  these  affec- 
tions at  a  distance  from  the  original  lesion  led  to 
the  belief  at  one  time  that  gonorrhoea  was  a  virulent 
disease,  and  that  the  virus,  by  absorption,  produced 
these  remote  symptoms.  It  is  now  generally  ad- 
mitted that  this  view  is  erroneous  ;  that  these  fibrous 
tissues  are  liable  to  attack  just  as  is  the  fibrous  tissue 
in  the  urethra  of  the  male  ;  and  this  theory  derives 
additional  support  from  the  fact  that  women  who  are 
very  rarely  indeed  attacked  by  urethral  gonorrhoea, 
seldom  suffer  from  rheumatism. 

Gonorrhoeal  rheumatism  generally  comes  towards 
the  end  of  a  clap,  although  there  are  exceptions  to 
this  rule,  and  invades  joints  in  preference  to  other 
parts — usually  the  knee,  the  elbow,  and  the  wrist. 
Occasionally  very  acute,  and  attended  with  a  marked 
degree  of  inflammation,  its  general  course  is  a  sub- 
acute one,  with  swelling  and  pain.  Shortly  after  the 
access  of  the  disease,  effusion  of  fluid  takes  place 
into  the  joint,  accompanied  with  an  increase  of  pain, 
continuing  in  this  condition  for  a  time  varying  from 
two  weeks  to  several  months  ;  the  fluid  is  gradually 
absorbed,  and  the  joint  may  be  restored  to  its  former 
usefulness.  Unfortunately,  however,  this  is  not  al- 
ways the  case  ;  ligamentous  adhesion  takes  place, 
and  anchylosis,  partial  or  complete,  is  the  final  re- 
sult.    I  know  of  no  cases  more  disheartening  and 


COMPLICATIONS  IN  GONORRHCEA.         157 

annoying  in  the  entire  range  of  venereal  affections 
than  those  of  gonorrhceal  rheumatism,  both  on  ac- 
count of  their  chronic  course  and  because  the  results 
of  treatment  are  but  too  often  unsatisfactory. 

The  tendons  come  next  to  the  joints  in  point  of 
frequency  of  attack,  and  then  the  muscles.  Of  the 
former,  the  tendo-Achillis  is  the  one  most  likely  to 
suffer,  and  when  it  is  attacked,  the  disease  runs  a 
long  and  painful  course,  not  so  much  from  swelling, 
for  this  is  often  trifling,  but  from  the  steady  aching 
of  the  part  and  the  consequent  impediment  to  walk- 
ing. In  very  severe  cases  a  permanent  contraction 
of  this  tendon  results,  producing  a  talipes  equinus, 
for  which  tenotomy  is  the  only  relief. 

Another  peculiar  symptom  occasionally  met  with 
in  this  stage  of  gonorrhoea  is  a  persistent,  boring 
pain  in  the  os  calcis,  unattended  by  redness  or  any 
enlargement  of  the  bone  or  thickening  of  the  perios- 
teum. 

It  is  chronic  in  its  course,  and  is  very  apt  to  occur 
in  nervous  men.  I  recall  one  case  where  it  had  last- 
ed for  several  years.  Indeed  I  am  inclined  to  re- 
gard it  as  a  neurosis  rather  than  a  periostitis. 

Until  within  a  few  years  it  was  believed  that  the 
heart  escaped  in  gonorrhceal  rheumatism,  differing 
in  this  respect  from  the  ordinary  form  of  rheuma- 
tism. This  is,  however,  a  fallacy ;  the  pericardial 
sac,  as  well  as  the  valves  of  the  heart,  are  affected. 
The  patient  complains  of  praecordial  pain,  attended 


158  VENEREAL  DISEASES. 

sometimes  with  dyspnoea,  when  an  examination  re- 
veals an  effusion  into  the  pericardium,  and  the  heart- 
sounds  are  muffled.  As  this  subsides,  a  souffle  is 
heard  at  the  aortic  and  mitral  valves,  sometimes 
with  regurgitation. 

Gonorrhoeal  ophthalmia  has  been  divided  in  many 
treatises  on  Venereal  into  two  varieties  :  one  which 
is  due  to  the  presence  of  gonorrhoeal  pus  in  the  eye ; 
the  other,  analogous  to  what  take  place  in  gout,  an 
irido-scleritis  rather  than  a  true  ophthalmia.  The 
latter  is  the  only  bona  fide  disease  which  belongs  to 
gonorrhoea,  the  first  one,  although  by  far  the  more 
serious  of  the  two,  being  nothing  more  than  a  puru- 
lent ophthalmia,  due  to  an  accidental  infection. 

The  first  symptom  of  which  the  patient  complains 
is  a  sensation  of  weakness  in  the  eye  ;  this  is  very 
seldom  associated  with  photophobia,  although  occa- 
sionally this  also  may  be  present.  Upon  examina- 
tion, the  conjunctival  and  sclerotic  vessels  will  be 
found  somewhat  congested,  the  iris  slightly  infiltra- 
ted, with  a  sluggish  pupil,  the  anterior  chamber  dis- 
tended with  fluid  containing  occasionally  some  floc- 
culi.  The  tension  of  the  eyeball  is  also  increased. 
As  the  disease  progresses,  the  anterior  capsule  of 
the  lens,  as  well  as  Descemet's  membrane,  becomes 
opaque  and  the  cornea  loses  its  transparent  look. 

This  condition  lasts  for  some  days,  when,  under 
proper  treatment,  the  symptoms  subside  ;  the  iris, 
the  capsule  of  the  lens,  and  the  cornea,  resume  their 


COMPLICATIONS  IN  GONORRHCEA.  159 

normal  appearance,  and  the  disease  passes  off,  leav- 
ing the  eye  none  the  worse  for  the  attack. 

Not  so,  however,  with  the  purulent  variety.  Here 
the  situation  is  very  grave,  and,  unless  active  meas- 
ures are  speedily  adopted,  the  eye  is  irretrievably 
injured,  the  contents  of  the  ball  being  evacuated  in 
forty-eight  hours,  or  even  in  less  time.  This  disease 
is  due  to  conveyal  of  the  pus  from  the  genitals  to  the 
eye,  and  the  right  one  is  the  one  most  frequently 
affected,  for  the  simple  reason  that  there  are  more 
right-  than  left-handed  people.  The  symptoms  no- 
ticed are  lachrymation,  photophobia,  intense  con- 
gestion of  the  conjunctival  vessels,  together  with  a 
thick,  purulent  discharge.  Both  lids  speedily  become 
oedematous  and  enormously  swollen,  so  much  so  as 
to  completely  close  the  eye.  If  the  lids  be  gently 
separated,  the  conjunctival  and  palpebral  mucous 
membrane  will  be  found  swollen  and  perfectly  scar- 
let in  hue.  The  former,  from  the  swelling,  is  very 
much  elevated  above  the  cornea,  leaving  this  latter 
imbedded  in  the  inflamed  tissue,  like  a  watch-glass 
in  its  setting.     This  swelling  is  known  as  chemosis. 

The  cornea,  curiously  enough,  is  at  first  unaffected, 
but  it  rapidly,  from  pressure  and  interference  with 
its  nutrition,  becomes  opaque,  pus  forms  in  the  inter- 
stitial layer,  which,  pushing  through  the  epithelial 
covering,  leaves  behind  ulcerations  of  the  cornea  ; 
this  tissue  softens,  and  the  tension  of  the  eyeball  be- 
ing great,  the  lens  and  vitreous  humor  are  evacuated 


l60  VENEREAL   DISEASES, 

through  the  opening.  In  other  words,  the  eye  is 
completely  lost. 

While  this  is  going  on,  the  abundant  purulent  se- 
cretion is  poured  out  over  the  cheeks,  producing  ex- 
coriation of  the  skin  of  these  parts.  Occasionally 
the  pressure  upon  the  lids  is  so  great  from  the  oedema 
that  gangrene  ensues,  sloughing  of  the  lids  occurs,  and 
greater  or  less  deformity  follows. 

Under  prompt  treatment,  thoroughly  carried  out, 
the  eye  may  be  saved  ;  but  opacity,  with  some  ulcera- 
tion of  the  cornea,  nearly  always  results.  The  oede- 
ma subsides,  the  chemosis  disappears,  and  the  con- 
junctival congestion  abates  in  intensity.  A  thick- 
ened and  granular  condition  of  the  palpebral  mucous 
membrane  remains,  however,  for  a  long  time  after, 
which  requires  steady  and  constant  care  to  cure. 

Gonorrhoeal  discharges  from  the  nose  and  mouth 
have  been  spoken  of  as  occurring  in  some  few  rare 
instances.  These  are  rare  indeed,  if  they  ever  do 
occur,  and  the  reported  cases  are  by  no  means  con- 
vincing. 

In  addition  to  the  above-mentioned  complications 
which  occur  in  the  course  of  a  clap,  there  are  two 
diseases  which,  although  not  strictly  complications, 
are  frequently  found  with  gonorrhoea,  or  else  are  the 
indirect  results.  They  are  commonly  known  as 
venereal  warts  and  herpes.  The  term  venereal  warts 
is  another  one  of  those  misnomers  which  abound  in 
the  literature  of  venereal  diseases  ;  for  although  some- 


COMPLICATIONS  IN  GONORRHCEA.         l6l 

times  found  with  a  gonorrhcea,  they  may  be  abso- 
lutely and  entirely  independent.  They  are  usually 
seated,  in  the  male,  upon  the  mucous  membrane  of 
the  glans  penis,  the  inner  lamella  of  the  prepuce, 
upon  the  scrotum,  and  sometimes  upon  the  perineum 
and  the  pourtour  of  the  anus  ;  in  the  female,  they 
occur  upon  the  mucous  membrane  of  the  labia  majora 
et  minora,  upon  the  perineum,  and  about  the  anus. 
They  occur  as  papillary  excrescences,  raised  above 
•the  surface  of  the  mucous  membrane,  exceedingly 
vascular,  bright  red  in  color,  and,  when  favored  by 
heat  and  moisture,  are  of  exuberant  growth.  They 
are,  indeed,  nothing  but  hypertrophy  of  the  natural 
papillae  of  the  parts,  and  are  particularly  prone  to 
attack  those  who  are  careless  of  their  personal  clean- 
liness. They  may  attain  to  enormous  size,  and  I  have 
seen  cases  where  the  head  of  the  penis  was  trans- 
formed into  an  enormous  bulbous  mass,  resembling 
a  cauliflower,  entirely  obliterating  all  semblance  to  the 
ordinary  virile  member.  Their  shape  varies  somewhat 
with  their  location,  and  when  they  are  compressed, 
as,  for  example,  when  seated  on  the  perineum,  or  in 
the  cleft  of  the  nates,  they  grow  in  the  shape  of  a 
cock's  comb,  being  long,  pointed,  and  serrated.  In 
the  female,  we  find  them  most  exuberant,  and  they 
sometimes  extend  from  the  anus  over  the  perineum 
and  vulva,  up  even  into  the  groins,  assuming  the  most 
grotesque  appearances,  and  from  attrition  and  dirt 
give  rise  to  a  very  offensive  and  acrid  discharge. 


1 62  VENEREAL  DISEASES. 

Herpes  is  another  manifestation,  although  not 
strictly  venereal  in  its  origin,  which  it  behooves  you 
to  know  something  about,  inasmuch  as  it  is  fre- 
quently confounded  with  superficial  chancroids  or 
mucous  patches  of  the  glans  penis.  It  appears  upon 
the  mucous  membrane  of  the  prepuce  and  glans 
penis  as  a  group  of  minute  vesicles,  five  or  six  in 
number,  seated  upon  a  slightly  inflamed  base. 
These  vesicles  rapidly  coalesce,  and  in  the  course  of 
twenty-four  or  thirty-six  hours  are  denuded  of  their*, 
epithelium,  when  they  present  superficial  erosions, 
which  are  sometimes  covered  with  a  whitish  pellicle. 
If  seen  early  in  their  course,  before  the  vesicles  are 
broken,  there  will  be  no  diflficulty  in  recognizing  the 
disease  ;  but  when  the  vesicles  have  become  eroded 
it  is  sometimes  extremely  difficult  to  distinguish  them 
from  superficial  chancroids  and  mucous  patches.  Its 
non-auto-inoculability,  the  rapidity  with  which  it 
recovers  under  simple  treatment,  its  non-tendency  to 
spread,  and  its  history,  will  serve,  in  most  cases,  to 
prevent  you  from  mistaking  it  for  the  first ;  and  the 
absence  of  ail  syphilitic  history  and  concomitant 
symptoms  of  the  pox,  will  save  you  from  mistaking 
it  for  the  second  class  of  these  diseases.  It  is  some- 
times due  to  local  causes  of  irritation,  but  quite  fre- 
quently it  is  associated  with  digestive  disturbances, 
induced  by  over-indulgence  in  eating  and  drinking. 


LECTURE   XII. 

TREATMENT     OF     GONORRHOEA     AND      ITS     COMPLI- 
CATIONS. 

Of  all  the  venereal  diseases  which  demand  treat- 
ment at  the  hands  of  the  surgeon,  gonorrhoea  is  the 
most  uncertain  and  disagreeable.  The  number  of 
nostrums  that  have  been  sold  for  its  cure  are  innu- 
merable, and  almost  every  medical  man  has  some 
pet  plan  of  procedure,  which,  in  the  long  run,  turns 
out  to  be  neither  better  nor  worse  than  others  which 
have  been  in  use  since  gonorrhoea  was  recognized  as  a 
curable  disease.  Some  writers  decry  the  use  of  in- 
jections as  provocative  of  stricture,  and  undoubtedly, 
if  improperly  used,  they  may  do  more  harm  than 
good  ;  while  others  assure  their  readers  that  injec- 
tions are  the  safest  and  best  remedies  for  the  cure 
of  the  disease.  To  this  latter  view  I  give  my  ad- 
herence ;  and,  while  recognizing  the  fact  that  local 
remedies  are  the  mainstay  in  the  treatment  of  the 
disease,  I  do  not  go  so  far  as  to  exclude  internal 
treatment ;  not  arguing  from  that,  that  the  internal 
treatment  is  essential  to  the  cure  of  a  gonorrhoea, 
but  only  that  there  are  certain  remedies  which  may 


l64  VENEREAL  DISEASES. 

advantageously  be  given  through  the  stomach  to 
ultimately  act  with  benefit  upon  the  diseased  ure- 
thral mucous  membrane. 

I  shall  first  consider  the  treatment  of  an  uncom- 
plicated case  of  gonorrhoea,  reserving  that  of  the 
complications  for  subsequent  discussion.  You  will 
please  remember  that  gonorrhoea  is  a  catarrhal  affec- 
tion of  a  certain  mucous  membrane,  and  that  it  is 
entirely  local.  In  its  very  earliest  stages,  before 
the  discharge  has  become  purulent,  a  treatment 
called  the  abortive  is  advised  in  many  treatises  on 
Venereal.  This  consists  in  adding  to  the  already 
existing  inflammation  a  more  severe  one,  in  the 
hopes  that  the  greater  will  remove  the  less,  which 
is  done  by  injecting  a  strong  solution  of  nitrate 
of  silver  into  the  urethra,  limiting  its  action  to  that 
portion  which  is  already  diseased.  I  beg  you  to 
have  nothing  to  do  with  it,  as,  from  repeated  trials 
of  this  method,  I  am  convinced  that  it  is  uncertain, 
is  liable  to  produce  very  acute  inflammation,  and 
oftentimes  serious  hemorrhage,  without  retarding 
or  checking  the  course  of  the  disease.  There  is  no 
royal  road  to  curing  a  clap  any  more  than  there  is 
to  the  acquisition  of  knowledge,  and,  in  the  treat- 
ment of  clap,  take  as  your  motto,  *'  festina  lente." 

The  best  injection  is  either  the  sulphate  or  acetate 
of  zinc  dissolved  in  water;  but  before  using  this  let 
me  explain  to  you  the  stage  of  the  gonorrhoea  in 
which  you  will  find  it  of  most  service.     During  the 


TREATMENT  OF  GONORRHCEA.  165 

acute  inflammatory  stage,  when  febrile  symptoms 
are  present,  when  the  penis  is  hot,  inflamed,  and 
oedematous,  when  the  mucous  membrane  of  the 
parts  is  congested,  and  there  is  eversion  of  the  hps 
of  the  meatus,  with  a  scanty  mucous  or  muco- 
purulent discharge,  your  first  object  should  be  to 
relieve  these  symptoms,  and  the  use  of  injections  in 
this  stage  is  entirely  inadmissible.  For  the  relief  of 
the  febrile  symptoms  I  know  of  nothing  which  will 
take  the  place  of  aconite,  in  small  doses  frequently 
repeated,  thus : 

"^ .     Aconit.  radici  tinct fT^i.-ij. 

Sig. — In  a  litde  water  every  hour. 

To  relieve  the  oedema  and  swelling  of  the  penis 
use  cold-water  dressings,  or  wrap  the  organ  up  in  a 
cloth  wet  with  the  lead  and  opium  wash,  which  is 
administered  as  follows : 

3r.     Liq.  plumb,  subacetat., 

Tinct.  opii aa   |  i. 

Aquae q.  s.  ad  3  viij, 

M. 

Sig. — Tocally. 

The  diet  during  this  stage  should  be  of  the  light- 
est, such  as  milk,  milk-porridge,  gruel,  and  the  fari- 
naceous articles  of  food.  These  symptoms  usually 
disappear  in  the  course  of  forty-eight  to  seventy-two 


1 66  VENEREAL  DISEASES. 

hours,  when  the  discharge  becomes  purulent  and 
abundant,  and  often  associated  with  a  frequent  desire 
to  pass  water,  not  from  any  invasion  of  the  neck  of 
the  bladder,  but  simply  from  reflex  action,  due  to 
the  local  irritation  within  the  first  inch  of  the  urethra. 
Now  is  the  time  to  begin  with  injections,  and  of 
these  the  best,  as  I  have  already  said,  are  the  prepa- 
rations of  zinc  : 

3  •     Zinc  sulph gr.  viij.-xij. 

Aquae ^  iv. 

M. 

Sig. — To  be  injected  thrice  daily. 

Or— 

5-.     Zinc  acet gr.  viij.-xij. 

Aquae |  iv. 

M. 

Sig. — Inject  thrice  daily. 

Alum,  either  alone  or  in  combination  with  tannin, 
as  well  as  tannin  alone,  have  been  advised  as  injec- 
tions, but,  in  my  estimation,  they  possess  no  advan- 
tages over  the  preparations  of  zinc.  They  may  be 
used  as  follows : 

1^..     Alumin.  sulph gr.  xx. 

AqucX 2  iv. 

M. 

Sig. — As  injection,  thrice  daily. 


TREATMENT  OF  GONORRHCEA.  1 6/ 

j^..     Alumin.  siilph., 

Acid,  tannic,  pulv aa  gr.  x.-xv. 

Aqute I  iv. 

M. 

To  be  well  shaken  before  using. 

Sig. — Inject  thrice  daily. 

One  of  the  objections  to  the  use  of  tannin  is  the 
persistent  stain  which  it  leaves  upon  the  body-linen, 
but  I  shall  shortly  mention  a  simple  manner  of  ob- 
viating this. 

An  injection  which  is  known  as  Ricord's  formula 
is  often  used,  and  is  an  excellent  one.  It  is  com- 
posed of  the  following  ingredients  : 

]^ .     Zinc,  sulph gr.  viij. 

Plumb,  acet gr.  xv. 

Tinct.  opii., 

Tinct.  catechu aa  3  ij. 

Aqu£e ad    §  iv. 

M. 

Sig. — As  injection,  thrice  daily. 

To  obviate  the  staining  of  the  clothes,  either  from 
the  disease  or  from  the  injections  used,  a  false  front 
may  be  made  by  pinning  to  the  shirt  a  double  fold 
of  unbleached  cotton  the  size  of  the  front  flap.  It 
also  has  the  advantage  of  keeping  the  parts  clean 
and  cool.  Never  countenance  wrapping  up  the 
penis  in  innumerable  folds  of  linen  or  cotton,  which 


1 68  VENEREAL  DISEASES. 

is  so  often  done,  as  it  keeps  the  parts  in  a  heated 
state,  prevents  the  free  exit  of  the  pus,  which,  from 
its  irritation,  is  very  prone  to  produce  balanitis  and 
oedema  of  the  prepuce. 

As  regards  injections,  there  are  some  points  to 
which  I  wish  to  call  your  attention,  for  upon  the 
proper  employment  of  this  class  of  remedies  will 
often  depend  the  efficacy  of  treatment.  In  the  first 
place,  never  use  a  glass  syringe  if  you  can  help  it ; 
the  fluid  nearly  always  comes  out  behind  the  piston 
instead  of  through  the  nozzle,  and  the  patient  re- 
ceives little,  if  any,  of  the  injection. 

The  syringes  made  of  vulcanized  rubber  are  the 
only  ones  which  are  fit  to  be  used,  but  even  some  of 
these  are  objectionable  from  their  inordinately  long 
nozzle,  which,  when  inserted  within  the  meatus, 
throw  the  injection  beyond  the  seat  of  disease.  No 
urethral  syringe,  designed  for  use  during  the  earlier 
stages  of  clap,  should  have  anything  but  a  very 
short  point,  and  the  best  are  those  which  terminate 
in  a  cone.  See  that  the  piston  works  easily  and 
readily,  without  any  jerking  movement,  and  that  it 
admits  of  no  leaking  behind  ;  also  be  careful  that 
the  instrument  is  sufficiently  large  to  hold  a  couple 
of  drachms  of  fluid.  The  little  pocket-syringes  which 
are  sold  in  shops  are  catch-penny  affairs. 

Now  as  to  using  it.  The  syringe  being  carefully 
charged  with  the  injection,  and  all  air  excluded  from 
the  barrel,  the   patient   holds   the   instrument   in   his 


TREATMENT  OF   GONORRHCEA.  1 69 

right  hand,  between  the  thumb  and  second  finger, 
the  index-finger  being  stationed  at  the  butt-end  of 
the  piston.  The  penis  is  held  between  the  second 
and  third  fingers  of  the  left  hand,  the  palm  looking 
upward,  the  index  finger  and  thumb  being  left  free  to 
separate  the  lips  of  the  urethra.  The  nozzle  of  the 
syringe  is  then  carefully  inserted  just  within  the  mea- 
tus, when  the  end  of  the  urethra  is  closed  against  the 
instrument  by  a  gentle  lateral  pressure.  Do  ;/^^  place 
the  finger  and  thumb  above  and  below  the  meatus, 
otherwise  you  will  open  the  canal  instead  of  closing 
it,  and  the  fluid  will  escape  as  fast  as  it  is  injected  ; 
but  make  a  gentle  pressure  sideways,  and  if  this  be 
properly  done,  none  of  the  fluid  will  run  out.  Now 
with  the  right  hand  gently  drive  the  piston  home, 
without  any  sudden  movement,  and  if  the  syringe  is 
in  proper  working  order,  this  is  readily  accomplished. 
As  soon  as  this  is  done,  and  all  the  fluid  deposited 
within  the  urethra,  with  a  quick  movement  withdraw 
the  nozzle  of  the  syringe  from  the  urethra  with  the 
right  hand,  while  with  the  thumb  and  index  finger  of 
the  right  hand  still  in  position,  the  patient  closes  the 
meatus.  This  prevents  the  outflow  of  the  injection. 
Then  laying  the  syringe  down,  the  patient  with  his 
right  hand  gently  strokes  the  floor  of  the  urethra 
from  behind  forwards  in  order  to  press  the  fluid  as 
far  as  possible  into  the  anterior  portion  of  the  canal, 
which  is  the  seat  of  the  disease  in  the  earlier  stage. 
As  the  disease  invades  deeper  parts,  this  motion  must 
8 


170  VENEREAL  DISEASES. 

be  reversed  in  order  to  crowd  the  fluid  backwards. 
After  the  injection  has  been  retained  from  two  to  five 
minutes,  the  compression  with  the  left  hand  upon  the 
Hps  of  the  meatus  may  be  discontinued,  when  a  por- 
tion of  the  fluid  will  run  out.  The  injection  should 
cause  a  slight  sensation  of  warmth  and  tingling  in 
the  canal  for  five  or  ten  minutes  after  its  use,  but  this 
should  never  amount  to  actual  pain  ;  if  it  does,  it 
shows  that  the  injection  is  too  strong",  and  it  must  be 
diluted. 

Before  using  the  injection,  it  is  a  good  plan  to 
make  the  patient  pass  his  water,  in  order  to  wash 
out  any  of  the  discharge  which  may  still  be  lodged 
in  the  urethra,  and  should  this  be  impossible,  cleanse 
the  canal  with  a  syringeful  of  tepid  water  before 
using  the  medication. 

Within  a  {^w  years  a  method  of  treating  gonor- 
rhoea by  means  of  medicated  bougies  has  been  advo- 
cated. They  are  made  of  coca  butter,  holding  an 
astringent  in  minute  subdivision,  and  are  left  within 
the  urethra  to  melt.  Experience  has  not  shown  me 
that  they  have  any  special  advantage  over  injections, 
and  they  have  the  decided  disadvantage  of  being 
dirty  and  disagreeable. 

Internal  treatment  consists  in  the  use  of  those  rem- 
edies which  are  excreted  by  the  kidneys,  and  which 
contain  a  balsam  or  resin  ;  foremost  among  these  are 
copaiba,  cubebs,  and  the  oil  of  yellow  sandal-wood. 
In  order  to   cover   their  nauseating  taste,    they  are 


TREATMENT  OF   GONORRHCEA.  I? I 

given  either  in  pill  form  or  in  capsule,  in  the  follow- 
ing manner  : 

^ ,    Copaibas |  i. 

Oleo-resin  cubebae |  ss. 

Magnesias q.  s. 

M.     Ut  ft.  niassa. 

Divide  into  pills  of  five  grains  each. 
Sig. — Three  to  six  three  times  daily,  after  meals. 

If  given  in  capsule,  the  balsam  of  copaiba,  the  oil 
of  cubebs,  or  the  oil  of  sandal- w^ood  is  employed,  each 
capsule  being  supposed  to  hold  ten  minims  of  these 
various  drugs. 

This  is  by  far  the  neatest  and  best  way  of  adminis- 
tering these  drugs,  as,  when  given  in  solution,  they 
are  extremely  nauseating,  and  are  apt  to  produce 
vomiting,  and  the  medicine  has  to  be  suspended. 
If  used  in  a  fluid  form,  what  is  known  as  Lafayette's 
mixture  is  the  least  objectionable.  The  following 
is  its  composition  : 

3.     Copaibae §  i. 

Liquoris  potassae §1]. 

Ext.  glycyrrhizae |  ss. 

Spiritus  aetheris  nitrici ^  i. 

Syrupi  acaciae |  vi. 

Olei  gaultheriae gtt.  xvi. 

M. 
The  copaiba  and  the  potassa  should  be  first  mixed  to- 
gether, the  liquorice  and  nitre  added  separately,  and  the 


172  VENEREAL  DISEASES. 

remaining  ingredients  together.  They  should  then  be 
thoroughly  incorporated  and  given  in  tablespoonful  doses 
p.  r.  n.  * 

These  preparations  have  the  effect  of  relieving  the 
ardor  urinae,  and  of  checking  the  discharge.  They 
should  always  be  given  after  meals,  as  they  are  then 
less  liable  to  disturb  the  stomach  or  to  produce 
nausea. 

Powdered  cubebs  is  sometimes  given  in  the  early 
stages  of  a  clap,  with  the  view  of  relieving  the  ardor 
urinae,  and  is  best  administered  in  the  form  of  a 
wafer,  which  is  easily  swallowed  and  prevents  the 
drug  from  being  tasted.  Its  action  seems  to  be  prin- 
cipally confined  to  rendering  the  passage  of  the 
urine  easy,  as  it  has  little  effect  upon  the  discharge.* 

Another  remedy  of  recent  use  is  the  kava-kava, 
or  piper  methisticum,  a  root  the  juice  of  which  is, 
or  used  to  be,  of  common  use  in  the  islands  of  the 
South  Pacific  Ocean  for  purposes  of  stimulation.  It 
is  generally  given  in  the  form  of  a  fluid  extract,  in 
doses  of  thirty  minims  to  a  drachm,  several  times 
daily.  I  have  not  used  it  sufficiently  to  enable  me 
to  decide  upon  its  actual  value  in  the  treatment  of 
these  diseases,  and  I  cannot  do  further  than  mention 
it  as  one    of  the  numerous  promising  remedies  ad- 

*  A  very  simple,  at  the  same  time  efifective,  way  of  relieving  the  ardor 
urinae  is  to  make  the  patient  pass  his  urine  in  a  tumi)ler  nearly  full  of 
hot  water  ;  in  other  words,  pass  his  water  under  water. 


TREATMENT  OF   GONORRHOEA.  173 

vised  in  gonorrhoea.  As  regards  the  others  I  have 
named,  I  can  speak  positively,  and  can  particularly 
commend  the  oil  of  the  yellow  sandal-wood.  Two 
objections  may  be  urged  against  it  :  first,  the  diffi- 
culty of  getting  it  pure  ;  and  second,  its  expense. 
If,  from  either  of  these  two  causes,  it  should  not  be 
given,  the  copaiba  is,  to  my  mind,  the  next  best 
drug  given  in  pill  or  capsule,  as  already  noted. 

The  stage  at  which  these  remedies  should  be  ad- 
ministered is  where  the  disease  begins  to  show  signs 
of  subsidence,  although  they  may  often  be  used 
when  there  is  much  pain  during  micturition,  and  a 
copious  discharge.  If  the  patient's  stomach  will 
bear  them,  the  effect  is  sometimes  wonderful ;  but 
their  long  continuance  is  liable  to  induce  pain  in 
the  region  of  the  kidneys,  and  a  deposit  in  the  urine 
which  has  been  mistaken  for  albumen. 

As  regards  diet,  the  rules  must  be  strictly  laid 
down,  and  no  deviation  allowed  until  the  disease  has 
entirely  disappeared.  Except  during  the  acute  in- 
flammatory stage,  the  patient  should  not  be  kept 
upon  a  low  diet,  but  ought,  on  the  contrary,  to  be 
allowed  a  good  and  nutritious  regimen.  Meat, 
vegetables,  fish,  eggs,  and  the  like  may  be  allowed, 
and  I  beg  you  to  remember  that  by  half-starving 
your  patient  you  only  tend  to  keep  up  the  gonor- 
rhoea. Asparagus,  highly  spiced  dishes,  strong  cof- 
fee or  tea,  and,  above  all  things,  every  form  of  alco- 
holic   or    malt    beverage,    as   well    as    immoderate 


174  VENEREAL  DISEASES. 

smoking  of  tobacco,  should  be  interdicted  in  the 
majority  of  cases  ;  but  if  the  patient  has  been  accus- 
tomed to  use  them,  a  weak  cup  of  coffee  or  tea  well 
diluted  with  milk  may  be  allowed  once  daily.  Lem- 
onade, the  copious  use  of  mineral  waters,  and  cider, 
should  also  be  tabooed,  and  the  patient  confine  him- 
self to  water  or  milk  as  drinks.  Flaxseed-tea  has 
been  recommended,  but  it  is  usually  such  a  nauseous 
mess  that  the  patient  is  only  too  glad  to  drop  it  out 
of  his  list  of  beverages.  In  the  summer-time  there  is 
no  objection  to  the  use  of  the  ripe  fruits,  and  their 
juice  often  makes  an  agreeable  addition  to  water  ; 
but  such  drinks  should  be  sparingly  sweetened,  as  a 
portion  of  the  sugar  is  converted  into  alcohol  in 
its  passage  through  the  human  system. 

The  use  of  injections  in  the  female  deserves  a  few 
words.  The  amount  injected  is  much  greater  than 
in  the  male,  and  is  employed  in  conjunction  with 
other  remedies,  which  should  never  be  used  except 
by  the  surgeon.  The  vagina  being  first  cleansed  by 
the  use  of  tampons  of  prepared  cotton,  introduced 
through  the  speculum,  should  then  be  painted  over 
with  a  strong  solution  of  nitrate  of  silver  (gr.  xx.-xL, 
to  aq.  3  i.)  or  the  pure  tincture  of  iodine.  If  care  is 
taken  not  to  allow  the  fluid  to  run  out  upon  the  vulva 
or  the  external  genitals,  no  pain  is  felt,  as  the  vagina 
and  the  cervix  uteri  are  not  sensitive  parts;  and  even 
if  the  medication  does  reach  those  portions,  the  smart- 
ing is  not  very  severe,  nor  does  it  last  long.     Upon 


TREATMENT  OF   GONORRHCEA.  1/5 

the  withdrawal  of  the  speculum  a  layer  of  dry  cotton 
is  placed  between  the  labia  to  separate  them  as  well 
as  to  prevent  the  discharge  from  trickling  down  over 
the  perineum  and  the  inside  of  the  thighs,  and  to 
obviate  excoriation  of  these  parts.  The  patient  should 
then  be  directed  to  use  one  of  the  following  injections 
in  the  manner  I  shall  describe  to  you  in  a  few  mo- 
ments : 

]5 .     Aluminis  pulv 3  i.-  3  ij. 

Aquae  tepidse §  viij.-xij. 

Inject  thrice  daily. 

Or— 

^ .     Ac.  tannic 3  ss.-  3  i. 

Aquae  tepidae 3  viij.-xij. 

M. 

Inject  thrice  daily. 

Or  these  two  may  be  combined,  thus  : 

^ .     Alum,  pulv 3  i.-  3  ij. 

Ac.  tannic 3  ss.-  3  i. 

Aquae  tepidae 3  viij.-xij. 

M. 

Inject  twice  daily. 

Remember,  however,  that  the  tannic  acid  stains 
-permanently,  and  some  w^omen  object  to  having 
this  constant  reminder  of  a  former  clap  on  their 
linen. 


176  VENEREAL   DISEASES. 

A  very  good  injection  is  to  add  to  a  half-pint  bot- 
tle of  ordinary  table  claret — 

Alum,  pulv !  ij. 

Zinci  sulph §  i. 

of  which  the  patient  is  directed  to  use  from  one  to 
three  tablespoonfuls,  in  from  one-half  to  a  full  pint  of 
tepid  water,  thrice  daily. 

It  is  well,  for  convenience,  to  give  women  the  ma- 
terials in  bulk  and  let  them  mix  their  injection  them- 
selves, reckoning  a  teaspoonful  as  the  equivalent  of 
the  drachm. 

If  the  inflammation  is  very  acute,  no  injection 
should  be  used,  except  one  of  hot  water  and  the  fre- 
quent use  of  Jiot  sitz-baths  is  advisable,  but  as  soon 
as  the  symptoms  subside,  the  medicated  fluids  should 
be  employed. 

A  ver}'-  good  method  of  keeping  the  astringent  in 
constant  apposition  with  the  diseased  mucous  mem- 
brane, is  by  the  use  of  vaginal  suppositories,  which 
may  be  made  of  the  strength  of  gr.  ij.-v.  of  the  astrin- 
gent to  each  suppository.  A  very  good  substitute  is 
to  soak  a  pledget  of  prepared  cotton  in  a  solution  of 
tannic  acid  3ij.,  to  glycerine  |i.,  and  lay  it  on  the 
diseased  parts.  Other  astringents  may  be  used  in 
the  same  manner,  such  as  alum  of  the  same  strength 
as  the  tannin  given  above,  or  the  tincture  of  catechu 
without  the  glycerine.  Be  careful  to  remove  these 
tampons  frequently  (three  or  four  times  daily),  else 


TREATMENT  OF   GONORRHCEA.  177 

trouble  will  ensue  from  decomposition  of  the  retained 
discharge,  and  also  remember  that  in  all  these  diseases 
cleanliness,  if  not  superior,  is  next  to  godliness. 

In  using  injections,  in  order  to  make  them  effec- 
tive the  following  rules  should  be  observed.  The 
glass  and  rubber  syringes  which  are  often  sold  under 
the  name  of  vaginal  syringes,  are  of  no  earthly  use  ; 
the  only  effective  one  is  the  Davidson's  rubber  syringe, 
or,  better  yet,  the  vaginal  douche  invented  by  Dr. 
Frank  P.  Foster,  of  New  York  City.  In  giving  an 
injection,  the  woman  should  never  be  allowed  to  as- 
sume a  squatting  posture,  as  the  fluid  runs  out  as 
fast  as  it  is  thrown  in,  and  does  not  reach  the  deeper 
portions  of  the  canal  ;  but  she  should  be  placed  upon 
her  back,  with  the  hips  slightly  elevated,  when  the  va- 
gina is  by  the  force  of  gravity  thrown  open,  and  the 
fluid,  by  the  same  physical  action,  is  carried  into 
every  portion  of  the  canal.  Some  of  the  fluid,  of 
course,  escapes ;  and  in  order  to  protect  the  woman's 
clothing,  a  sheet  of  rubber  cloth  should  be  placed 
under  the  hips,  and  a  vessel  in  readiness  to  catch  the 
overflow.  Foster's  vaginal  douche  is  better  yet,  in- 
asmuch as  it  has  an  overflow  pipe  to  carry  off  the 
superabundant  fluid,  and  the  injection  can  thus  be 
administered  with  thoroughness  and  convenience. 
At  the  close  of  the  operation,  a  tampon  of  dry  cotton 
should  be  placed  between  the  labia,  to  retain  what 
fluid  is  left  in  the  canal.  These  injections,  remember, 
are  to  be  used  in  conjunction  with  the  applications 
8* 


178  VENEREAL  DISEASES. 

which  the  surgeon   makes  himself  every  second  or 
third  day. 

The  treatment  of  the  compHcations  in  gonorrhoea 
vary  according  to  their  character.  For  balanitis,  the 
most  important  point  to  be  observed  is  cleanliness, 
and  this,  in  many  cases,  will  be  all  that  is  required. 
In  severe  cases,  upon  exposure  of  the  glans  penis  by 
retraction  of  the  prepuce,  the  parts  may  be  painted 
over  with  a  solution  of  nitrate  of  silver,  from  five  to 
ten  grains  to  the  ounce  of  water,  and  the  subsequent 
dressings  should  be  either  of  ordinary  starch  powder, 
the  impure  oxide  of  zinc  (calamine),  or  lycopodium, 
and  a  thin  layer  of  lint  or  prepared  cotton  placed 
between  the  prepuce  and  glans  penis. 

For  phimosis,  if  incomplete,  subpreputial  injections 
of  warm  water,  or  of  a  slightly  carbolized  lotion, 
with  proper  attention  to  cleanliness,  will  generally  be 
sufficient ;  when  it  is  complete,  and  especially  if  the 
foreskin  acts  as  a  reservoir  for  the  pus  and  urine,  cir- 
cumcision should  be  practised,  provided  the  inflam- 
mation is  not  very  acute,  and  there  be  no  oedema. 
There  is  no  danger  in  the  operation  so  far  as  the  clap 
is  concerned,  for  the  secretion,  you  know,  is  not  au- 
to-inoculable ;  but,  of  course,  be  careful  that  the  dis- 
charge does  not  come  from  concealed  chancroids  in- 
stead of  gonorrhoea,  and  auto-inoculation  will  here 
give  you  the  requisite  information  as  to  its  nature. 

Paraphimosis^  which  is  the  opposite  of  phimosis, 
is  relieved  by  compression  of  the  glans  penis   with 


TREATMENT  OF  GONORRHCEA.  179 

the  right  hand  so  as  to  squeeze  all  the  blood  from  the 
part ;  traction  forwards  of  the  prepuce  is  then  made, 
by  grasping  it  posterior  to  the  constricted  portion 
between  the  fingers  and  thumb,  which  are  held  in  the 
shape  of  a  circle,  the  penis  lying  in  the  enclosed  space 
between  the  fingers.  At  the  same  time  that  the  for- 
ward movement  is  made,  the  glans  is  pushed  back- 
wards in  the  hopes  of  forcing  it  beneath  the  constric- 
tion. If  this  be  not  successful,  an  incision  must  be 
made  through  the  strictured  portion  of  the  foreskin, 
when  the  prepuce  can  be  drawn  forward  over  the 
glans,  and  as  soon  as  the  inflammation  and  thicken- 
ing of  the  foreskin  has  subsided,  the  unseemly  dog's 
ears  which  are  left  behind  may  be  removed  by  cir- 
cumcision. 

Chordee^  of  all  complications,  is  the  one  that  will 
put  you  to  your  trumps  to  relieve.  Everything  in 
the  pharmacopoeia  has  been  tried,  and,  I  might  almost 
say  with  truth,  has  been  found  wanting.  Lupulin, 
camphor,  belladonna,  opium,  bromide  of  potassium, 
ice,  and  hot  water  have  all  been  used  with  varying 
success  ;  but,  to  my  mind,  the  one  remedy  which 
gives  the  most  relief  is  the  hypodermic  injection  of 
morphia  and  atropia,*  given  in  the  perineum  or  the 

*  I^.     Atropias gr.  i. 

Acidi  acetici q.  s.  ut  ft.  solutio  cum. 

Aqua  destil 3  iv.  , 

Et  adde, 

Magendie's  solution  of  morphia  q.  s.  ad  unciam  unam. 

Of  this  inject  5-8  minims  hypodermically. 


l8o  VENEREAL  DISEASES. 

inside  of  the  thighs  at  bed-time.  In  giving  these  in- 
jections in  the  perineum,  you  must  of  course  be  care- 
ful not  to  wound  the  membranous  urethra  by  carry- 
ing the  needle  too  deep  ;  and  if  you  select  the  inside 
of  the  thighs,  be  careful  not  to  puncture  the  internal 
saphenous  vein.  All  of  these  dangers  may  be  avoided 
by  making  your  punctures  just  beneath  the  skin.  Of 
the  internal  administration  of  remedies,  camphor  and 
opium,  or  camphor  and  belladonna,  or  opium  and 
belladonna,  give  the  best  results,  thus  : 

Vf> .     Pulv.  opii gr.  i. 

Pulv.  camph gr-  ij. 

Sacch.  alb q.  s. 

Ut  fiat  capsula  una. 
Sig. — One   at   bed-time,    and    repeat    in    two    hours   if 
necessary. 

5.     Belladon.  extr.  alcohol gr.  ss.-i. 

Camph.  pulv gr.  ij.-iv. 

Ut  fiat  capsula  una. 
Sig. — One  at  bed-time,  and  repeat  if  necessary. 

I^ .     Pulv.  opii gr.  i.-ij. 

Extr.  belladon.  alcohol gr.  ss.-i. 

Ut  fiat  i)il.  una. 
Sig. — At  bed-time,  and  repeat  if  necessary. 

The  genital  organs  may,  in  addition,  be  bathed  at 
bed-time   in   perfectly  Jiot  water,  which  will   some- 


TREATMENT  OF   GONORRHCEA.  l8l 

times  relieve  the  tendency  towards  erection,  and  the 
hot  I  have  found  of  more  service  than  cold  applica- 
tions. A  method  of  immediate  relief  more  generally 
practised  among  the  lower  orders  abroad  than  here, 
is  to  place  the  penis  during  the  state  of  erection  upon 
a  table  or  flat  surface  and  strike  it  a  smart  blow  with 
the  fist  upon  its  convex  surface.  It  certainly  relieves 
the  chordee  at  once,  but  at  the  expense  of  profuse 
hemorrhage  and  a  subsequent  traumatic  stricture, 
for  the  urethra  is  ruptured  by  the  blow.  It  is  hardly 
necessary  for  me  to  add  that  I  do  not  advise  your 
practising  any  such  method. 

When  the  testicles  are  affected,  the  first  step  in  the 
treatment  is  to  insist  upon  the  patient's  going  to  bed, 
and  the  old  maxim  of  Malgaigne  in  such  cases  is  a 
good  one  :  **  The  patient  on  his  back,  and  his  testicles 
towards  the  ceiling."  If  the  patient  should  at  first 
be  restive  under  such  advice,  you  may  be  very  sure 
that  sooner  or  later  he  will  accede  to  it,  for  his  tes- 
ticles will  continually  remind  him  that  he  is  a  fool  to 
stand  when  he  can  lie,  and  he  will  perforce  be  glad 
to  seek  his  bed  to  escape  the  intense  suffering  which 
gonorrhoeal  epididymitis  involves.  If  the  inflamma- 
tion be  very  acute,  leeches  should  be  applied  ;  but  I 
strongly  advise  you  never  to  put  them  upon  the 
scrotum.  I  know  it  is  done,  and  sometimes  without 
producing  trouble  ;  but,  on  the  other  hand,  I  have 
seen  an  enormous  subcellular  infiltration  of  blood 
take   place,  which,  although   not   dangerous,  is  dis- 


1 82  VENEREAL  DISEASES. 

agreeable,  and  your  patient  already  suffers  sufficient 
discomfort  without  your  adding  to  it.  Place  the 
leeches,  then,  at  the  external  abdominal  rings,  at  the 
perineum,  or  along  the  inside  of  the  thighs,  and  let 
their  number  be  six  or  eight ;  in  other  words,  abstract 
blood  freely.  Unless  the  inflammation  be  very  acute, 
blood-letting  will  not  be  requisite,  as  other  remedies 
will  be  fully  as  serviceable  ;  and  of  these,  applications 
of  cold  are  the  best.  Pack  the  testicle  in  ice,  which 
should  be  finely  broken  up  and  placed  in  a  water- 
tight rubber  bag,  or,  what  will  answer  the  same  pur- 
pose, a  well-made  rubber  condom.  This  will  often 
relieve  the  pain  and  make  the  patient  comparatively 
comfortable  and  easy.  Poultices  of  hot  flax-seed 
meal,  or  of  tobacco  leaves,  soaked  in  hot  water,  are 
sometimes  used  ;  but  all  these  applications  are  nasty 
messes,  and  if  you  deem  heat  requisite  in  the  treat- 
ment of  these  diseases,  a  very  good  way  of  applying 
it  is  by  soaking  a  preparation  known  in  the  shops  as 
spongiopiline  in  hot  water,  and  wrapping  the  testicle 
up  in  that.  Flannels  wrung  out  in  hot  water  will 
oftentimes  serve  the  same  purpose  ;  but  nine  times 
in  ten  cold  applications  answer  better  than  hot  ones. 
The  ice  should  be  steadily  persevered  in  until  the 
pain  is  relieved,  unless,  indeed,  its  application  causes 
discomfort  to  the  patient  from  too  great  a  degree  of 
cold,  when  its  use  may  be  intermitted.  The  testicle, 
in  the  meantime,  should  be  well  supported  and  not 
allowed   to  hang   between  the  patient's  thighs.     A 


TREATMENT  OF   GONORRHCEA.  1 83 

very  neat  manner  of  relieving  the  pain  is  by  making 
multiple  punctures  with  a  surgeon's  needle,  the  larger 
the  better,  or  with  a  bistoury,  which  is  guarded  to 
within  a  quarter  of  an  inch  of  its  point.  The  testis 
is  grasped  in  the  left  hand  and  several  rapid  punc- 
tures are  made  into  the  swollen  epididymis,  care 
being  taken  not  to  make  them  too  deep.  Blood  and 
serum  follow  the  punctures,  and  oftentimes  immediate 
relief  is  experienced. 

After  a  week  or  ten  days  the  pain  in  the  testis 
subsides,  and  the  patient  is  able  to  leave  his  bed, 
when  upon  examination  the  epididymis  is  found  enor- 
mously enlarged  and  indurated,  and  still  tender  upon 
pressure.  This  swelling  gradually  subsides,  and 
under  very  favorable  circumstances  may  entirely  dis- 
appear, but,  as  I  already  stated  in  the  last  lecture, 
some  thickening  is  nearly  always  left  behind.  To 
reduce  this,  an  ointment  composed  of  equal  parts  of 
unguent,  hydrargyri  and  unguent,  belladonnae  may 
be  applied  to  the  testicles  upon  a  piece  of  linen  or 
soft  kid.  Another  plan,  but  one  little  used  at  the 
present  day,  is  strapping  the  testicle  in  the  manner 
described  in  your  manuals  on  surgery  ;  but  as  this 
has  sometimes  led  to  atrophy  of  the  testis,  its  general 
use  has  been  pretty  nearly  abandoned.  One  remedy 
which  has  been  lately  advocated  is  the  internal  ad- 
ministration of  tincture  of  pulsatilla,  which  is  used  in 
doses  of  one  minim,  or  fractions  of  a  minim,  repeated 
every  hour  for  twenty-four  to  forty-eight  hours.     In 


1 84  VENEREAL  DISEASES. 

the  cases  In  which  I  have  used  it,  I  have  been  rather 
pleased  with  the  results,  as  it  has  seemed  to  have  the 
effect  of  relieving  the  pain  rapidly,  although  it  has 
no  effect  upon  the  swelling.  The  preparation  which 
I  have  used  has  been  the  homoeopathic  mother  tinc- 
ture, which  is  better  prepared,  and  more  certain  in 
its  results,  than  the  non- officinal  preparations  which 
are  sold  by  the  druggists.  To  relieve  the  enlarge- 
ment of  the  epididymis,  iodide  of  potassium  in  5  or 
10  grain  doses,  three  times  daily,  is  sometimes  ad- 
vised, but  my  experience  has  been  that  this  salt 
makes  the  clap  worse.  I  therefore  have  given  up  its 
use,  and  substitute  for  it  the  simple  tincture  of  iodine, 
in  5  or  10  minim  doses,  which  I  do  not  find  open  to 
the  same  objection  as  the  iodide. 

The  treatment  of  prostatitis  is  twofold,  the  first 
being  directed  to  the  relief  of  the  inflammation  of 
the  prostatic  urethra,  and  the  second  to  the  preven- 
tion of  suppuration  in  the  swollen  organ.  The  symp- 
toms, you  remember,  of  prostatitis  and  cystitis  were 
very  similar ;  hence,  what  will  answer  for  one  will 
also  do  for  the  other.  If  the  prostate,  upon  rectal 
examination,  be  found  very  much  enlarged  and  ten- 
der, leeches  may  be  applied  to  the  perineum,  and  as 
soon  as  they  have  come  off,  hot  fomentations  should 
be  applied.  For  the  relief  of  the  dysuria,  rectal  sup- 
positories of  opium  and  belladonna  should  be  used, 
of  sufficient  strength  to  insure  freedom  from  pain. 
They  should  be  prepared  as  follows : 


TREATMENT  OF  GONORRHCEA.  1 85 

]^ .     Extr.  opii gr.  ij- 

Extr.  belladon gr.  i. 

Theobroma q.  s. 

M. 

Ut  fiat  suppos.  No.  I. 

Sig.  p.  r.  n. 

Pieces  of  ice  may  also  be  passed  up  the  rectum, 
and  kept  in  apposition  to  the  inflamed  prostate. 

Injections  in  both  prostatitis  and  cystitis  should  be 
suspended,  nor  should  they  be  resumed  until  the 
acute  inflammation  has  entirely  passed  away. 

The  internal  remedies  which  have  been  advised 
for  these  complications  of  gonorrhoea  are  numerous, 
but,  to  my  mind,  four-fifths  of  them  are  useless,  and 
had  better  be  dropped  out  of  the  list.  The  best  are 
copaiba,  or  the  oil  of  yellow  sandal-wood,  and,  if  a 
diluent  is  required,  sweet  spirits  of  nitre,  well  diluted 
with  water,  given  several  times  during  the  day  in  table- 
spoonful  doses.  The  homoeopaths  frequently  use  mi- 
nute doses  of  the  tincture  of  cantharides,  in  fractions 
of  a  minim  to  one  or  three  minims  every  hour ;  and, 
in  some  cases,  where  I  have  used  the  fly  in  these  mi- 
nute doses,  I  have  given  relief  when  the  neck  of  the 
bladder  was  implicated  ;  in  other  cases  it  has  entirely 
failed.  When  the  tincture  of  cantharides  is  used,  the 
preparation  should  be  fresh. 

When  suppuration  threatens,  the  formation  of  pus 
should  be  favored  as  much  as  possible  by  the  use  of 


1 86  VENEREAL   DISEASES. 

hot  sitz-baths  and  hot  fomentations  to  the  perineum, 
and  the  surgeon's  efforts  should  be  directed  to  make 
the  abscess  point  into  the  rectum.  As  soon  as  fluc- 
tuation is  felt,  open  it  and  dress  the  part  afterward 
with  injections  of  warm  water,  to  which  may  be  add- 
ed a  little  carbolic  or  nitric  acid,  but  these  should 
be  very  weak,  the  principal  object  being  to  keep  the 
abscess  clean  and  free  from  the  accumulation  of  pus 
or  faecal  matter.  The  cut  edges  of  the  wound  will 
often  form  a  sort  of  valve,  which  acts  as  a  protec- 
tion against  the  retention  of  foreign  bodies  in  the 
abscess. 

During  the  acute  inflammation  of  both  these  or- 
gans the  gonorrhoea!  discharge,  almost  if  not  en- 
tirely disappears,  to  return  again  as  soon  as  it  has 
passed  off,  and  when  this  occurs,  injections  can  again 
be  used.  The  patient  should  now  be  instructed, 
after  throwing  in  the  injection,  to  work  it  back  as  far 
as  possible  into  the  canal,  and  this  may  be  done  by 
stroking  the  urethra  from  before  backward,  in  order 
to  press  the  fluid  into  the  deeper  parts  of  the  canal. 
The  surgeon  may  himself,  two  or  three  times  a  week, 
make  a  deep  injection  with  a  long-nozzled  urethral 
syringe,  of  one  of  the  following  preparations  : 

]^.     Argent,  nitrat gr.  ss.-L 

Aquae J  vi. 

M. 

Sig. — For  deep  injections. 


TREATMENT  OF  GONORRHCEA.  1 8/ 

]^.     Tinct.  ferri  persulphat 3  ss.-  ^  i. 

Aquae 3  vi.-viij. 

M. 

Sig. — For  local  use. 

These  injections  should  never  be  intrusted  to  the 
patient,  but  the  surgeon  should  always  give  them 
himself. 

For  cozvperitis  and  inflammation  of  the  vesiculae 
there  is  little  to  be  done  beyond  rest,  the  application 
of  leeches  to  the  perineum,  and  the  use  of  the  rectal 
suppository  of  belladonna  and  opium.  If  suppura- 
tion threatens,  favor  it  as  far  as  possible,  and  as  soon 
as  the  abscess  is  ripe,  open  and  treat  it  as  you  would 
abscesses  elsewhere. 

After  the  discharge  has  lost  its  purulent  character 
and  subsided  into  the  condition  known  as  gleet,  the 
treatment  undergoes  certain  modifications.  If  the 
gleet  be  dependent  upon  a  stricture,  this  must  be 
removed  before  the  gleet  can  be  cured,  which  may 
be  done  either  by  gradual  dilatation  with  bougies 
and  sounds,  or  else  by  one  of  the  many  operations 
advised  in  your  text-books  on  surgery.  When  it  is 
not  dependent  upon  gleet,  but  is  due  to  a  subacute 
inflammation  of  the  deeper  portions  of  the  urethra, 
the  stronger  medicated  injections  should  be  stopped 
at  once,  and  cold  water  or  very  weak,  astringent  solu- 
tions thrown  into  the  canal  several  times  daily.  The 
surgeon  should,  twice  or  three  times  weekly,  pass  a 


1 88  VENEREAL   DISEASES, 

steel  sound  of  the  largest  size  the  urethra  is  capable 
of  receiving,  which  should  be  withdrawn  within  a 
few  seconds  after  its  introduction  into  the  bladder. 
A  steady  perseverance  in  this  course  of  treatment 
for  a  few  weeks  will  generally  bring  about  a  cure, 
and  it  may  be  hastened  in  some  instances  by  the 
internal  administration  of  the  balsamic  and  resinous 
preparations  of  which  I  have  already  spoken. 

This  brings  me  to  one  point  of  my  subject  which 
it  is  well  for  you  to  remember  :  a  discharge  is  some- 
times kept  up  by  over-medication.     Patients  will  apply 
to  you  with  the   following  history :   they  have  been 
under   treatment  two   or   three  months    for  a  gon- 
orrhoea,   which,    after    running     through    its    usual 
course,  has  ended  in  a  thin,  mucous   discharge,  per- 
haps only  apparent  in  the  morning,  and  occasionally 
during  the  day.     There  is  no  irritation  while  passing 
water,  and,  but  for  the  slight  discharge,  they  would 
be  entirely   well.     This,   however,   has  persisted   for 
several   weeks   without   any   apparent   change,    and 
has  been  a  source  of  worry  and  anxiety.     The  pa- 
tients have  lost  flesh   and   strength,   while  the  face 
will  often  bear  signs  of  the  mental  excitement  under 
which  they  are  laboring.     Rid  such   patients  throw 
away   their   syringes,    stop    all    injections   and   clap 
medicines  ;  bid  them   live  well,  and   use  with   their 
dinner  a  moderate  quantity  of  some  light  wine — the 
red   Bordeaux    wines    are    the   best ;    advise   them 
against  beer  and  spirits  at  the  start,  but  these  may 


TREATMENT  OF  GONORRHCEA.  189 

be  used  later  on  if  deemed  requisite.  Tell  them 
plainly  that  they  are  keeping  up  the  discharge  by 
over-treatment,  and  that  the  sooner  they  can  recog- 
nize the  fact  the  quicker  they  will  get  well.  Some- 
times nothing  further  wall  be  needed,  but  occasion- 
ally some  tonic,  such  as  the  tincture  of  the  chloride 
of  iron,  or  the  syrup  of  iodide  of  iron,  in  doses  of 
5  to  15  minims,  may  be  given  with  advantage,  and 
you  will  have  the  gratification  of  hearing  the  pa- 
tients tell  you  in  a  short  time  that  they  are  entirely 
well. 

I  am  bound  to  say,  how^ever,  that  some  cases  of 
gleet  will  last  for  years  in  spite  of  all  kinds  of  treat- 
ment ;  but  there  is  one  consolation  that  you  can 
afford  your  patient,  sorry  though  it  may  be,  that 
some  time  or  another  it  wall  come  to  an  end,  and  I 
have  seen  such  cases  recover,  apparently  from  noth- 
ing else  than  a  change  of  climate,  or  a  sea  voyage. 
These  cases,  however,  are  comparatively  few. 

The  treatment  of  gonorrhoeal  complications  in  the 
female  deserves  separate  consideration.  In  vulvitis^ 
one  of  the  first  things  to  impress  upon  the  patient's 
mind  is  attention  to  cleanliness,  inasmuch  as  the  dis- 
charge from  the  inflamed  parts  tends  to  keep  up  the 
cause  which  gave  rise  to  it,  and  also  to  produce  irrita- 
tion of  neighboring  parts.  The  surgeon  should  make 
an  application  every  two  or  three  days  of  a  weak 
solution  of  nitrate  of  silver,  one  to  three  grains  to  the 
fluid  ounce  of  water,  and  the  patient  directed  to  place 


I90  VENEREAL  DISEASES. 

pledgets  of  lint  or  prepared  cotton  between  the  in- 
flamed labia,  the  lint  being  previously  soaked  in 
solutions  of  alum  or  the  liquor  plumbi  subacetatis. 
They  may  be  prepared  as  follows  : 

3 .     Pulv.  alum gr.  x.-xv. 

Aquas §  i. 

M. 

For  local  use. 
Or— 

3..     Liquor,  plumb,  subacetatis,  one  part. 

Aquce,   two  parts. 
M. 

For  local  use. 

Such  cases  are  particularly  adapted,  during  the 
acute  stage,  for  the  use  of  the  dry  dressings  either  of 
lycopodium,  of  calamine,  or  finely  pulverized  starch. 
As  soon  as  the  acute  inflammation  passes  off,  the 
astringent  applications,  advised  above,  should  be 
made. 

The  inflammation  of  the  vulvo-vaginal  gland  may 
at  first  be  treated  in  the  hope  of  preventing  the  for- 
mation of  an  abscess,  and  this  is  done  by  painting 
the  part  with  a  ten-grain  solution  of  nitrate  of  silver, 
and  by  the  topical  application  of  equal  parts  of  bella- 
donna and  mercurial  ointment  applied  on  a  piece  of 
linen  or  cotton.  If  suppuration  be  inevitable,  hot 
sitz-baths  and  poultices  should  be  used  to  favor  the 
formation  of  matter,  and  the  resulting  abscess  open- 


TREATMENT  OF  GONORRHCEA.  IQI 

ed  as  soon  as  fluctuation  is  detected,  provided  the 
pus  cannot  be  evacuated  through  its  natural  duct. 

For  urethritis  there  is  nothing  better  than  the  use 
of  the  solid  stick  of  nitrate  of  silver  passed  over  the 
entire  surface  of  the  urethral  mucous  membrane, 
which  is  easily  accomplished,  owing  to  the  shortness 
and  peculiar  situation  of  the  urethra  in  the  female. 
The  pain  of  the  application  is  not  as  great  as  you 
might  imagine,  and  speedily  passes  away.  It  is  here 
that  the  internal  administration  of  copaiba,  cubebs, 
and  sandal- wood  oil  are  of  use  during  a  gonorrhoea  in 
women  ;  in  the  other  varieties  of  the  disease  they 
exercise  no  effect. 

In  inflammatioji  of  the  cervix,  the  part  should  first 
be  thoroughly  cleansed  from  all  discharge  with  a 
piece  of  cotton  wound  on  the  end  of  a  uterine  probe, 
and  the  canal  touched  with  a  solid  stick  of  the  nitrate 
of  silver,  care  being  exercised  that  the  cervix  alone, 
and  not  the  body  of  the  uterus,  is  cauterized.  The 
patient  should  not  be  trusted  to  make  any  applica- 
tions herself,  owing  to  the  danger  of  exciting  inflam- 
mation in  the  body  of  the  womb,  the  treatment  of 
this  portion  of  the  genital  apparatus  being  left  entirely 
in  the  surgeon's  hands.  When  the  body  of  the  uterus 
and  its  appendages  are  attacked  by  gonorrhoea,  the 
results  are  sometimes  very  serious  ;  peritonitis  and 
pelvic  cellulitis  resulting  from  the  discharge  flowing 
into  the  pelvic  cavity.  The  patient  should  be  at 
once  confined  to  bed,  and  local  abstraction  of  blood 


192  VENEREAL  DISEASES. 

by  leeches  resorted  to.  This  should  be  followed  by 
the  application  of  hot  fomentations  to  the  uterine  re- 
gion, and  by  the  internal  administration  of  opiates  in 
sufficient  quantity  to  keep  the  patient  free  from  pain. 
If  all  goes  favorably,  the  discharge  will  be  evacuated 
through  the  cervix  ;  under  other  circumstances,  pel- 
vic abscess  will  ensue,  which  will  be  evacuated  some- 
times through  the  vagina,  sometimes  through  the 
rectum,  and  sometimes  through  the  abdominal  walls. 
Gonorrhoeal  endometritis  is  always  a  serious  complica- 
tion, which  fortunately  is  not  of  frequent  occurrence. 

When  the  ovary  is  inflamed,  rest  in  bed,  leeches, 
hot  fomentations,  and  painting  over  the  inflamed 
spot  with  the  compound  tincture  of  iodine,  are  the 
best  means  to  be  employed. 

The  treatment  of  gonorrJiceal  rheiunatism  is  as  un- 
satisfactory as  it  can  well  be,  for  there  is  no  form  of 
rheumatism  which  is  more  rebellious  to  the  action  of 
remedies  than  this.  The  ordinary  internal  remedies 
are  of  no  avail,  and  those  which  promise  the  most 
success  are  the  local  application  of  blisters  above  and 
below  the  affected  joints,  painting  the  aflected  parts 
with  the  compound  tincture  of  iodine,  and  the  inter- 
nal administration  of  the  iodide  of  potassium.  But 
even  these  sometimes  prove  of  no  service,  and  the 
case  goes  on  to  anchylosis,  partial  or  complete.  In 
cases  where  pericarditis  ensues,  the  local  applications 
of  the  strong  tincture  of  iodine  should  be  made  ovef^^ 
the  pericardial  region,  and  the  iodide  of  potassium  in.4r) 


TREATMENT  OF   GONORRHGEA.  193 

five  to  ten  grain  doses  administered  internally  three 
times  daily.  But  sometimes  permanent  thickening 
of  the  cardiac  valves  takes  place,  just  as  it  does  in 
rheumatic  pericarditis  from  other  causes. 

GonorrJical  opJithalniia  is  of  importance,  according 
to  the  form  which  it  takes,  and  the  treatment  varies 
widely.  When  due  to  contagion  from  the  conveyal 
of  matter  by  the  fingers,  the  attack  is  extremely 
serious,  as  the  eyeball  may  be  destroyed  within 
forty-eight  hours,  unless  prompt  measures  be  taken 
for  its  relief.  The  eyelids  and  the  eye  itself  should 
be  kept  sedulously  and  carefully  clean  by  frequent 
syringing  with  warm  water  every  ten  or  fifteen  min- 
utes ;  the  eyelids  should  then  be  everted,  so  far  as  the 
enormous  oedema  and  swelling  will  permit,  and  the 
parts  brushed  over  with  a  strong  solution  of  nitrate 
of  silver  of  the  strength  of  40  to  60  grains  to  the  fluid 
ounce  of  water.  Where  the  oedema  and  chemosis  is 
very  great,  blood  should  be  abstracted  from  the  tem- 
ple by  leeches,  or  by  the  instrument  known  as 
Heurteloup's  artificial  leech,  or  by  incisions  into  the 
swollen  mucous  membrane.  Remember ^  never  to  put 
the  leeches  on  the  eyelids.  In  spite  of  all  care  and 
attention,  corneal  ulceration  will  sometimes  go  on 
very  rapidly,  and  the  contents  of  the  eyeball  be  evac- 
uated. The  subsequent  thickening  and  granular 
condition  of  the  lids,  as  well  as  the  keratitis  and 
chemosis,  should  be  treated  by  the  methods  laid 
down  in  the  text-books  on  ophthalmic  surgery. 


194  VENEREAL  DISEASES. 

The  other  form  of  gonorrheal  ophthalmia  is  not  so 
serious.  The  conjunctivitis  and  the  serous  iritis  may- 
be treated  in  the  case  of  the  former  by  repeated 
bathing  with  warm  water,  blisters  to  the  temples, 
and  the  instillation  of  the  following  collyrium  : 

I^ .     Sodc^  bicarbonat gr-  x. 

Aquae  camph ^  ij. 

M. 

Sig.  p.  r.  n. 

The  serous  iritis  may  be  treated  by  dropping  into 
the  eye,  three  or  four  times  daily,  the  sulphate  of 
atropia,  four  grains  to  the  ounce  of  water.  If  the  iris 
remains  sluggish  to  the  action  of  the  atropine,  one  or 
two  leeches  may  be  applied  to  the  temple  or  over 
the  supraorbital  region. 

Inflammation  of  the  lymphatic  inguinal  glands, 
or  those  running  over  the  dorsum  penis,  should  be 
treated  in  the  earlier  stage  by  rest,  leeches,  blisters, 
the  daily  application  of  the  tincture  of  iodine,  and 
the  internal  administration  of  the  sulphide  of  calcium, 
yV  to  I  of  a  grain,  three  times  daily. 

Should,  however,  these  measures  prove  ineffective 
to  prevent  suppuration,  it  should  be  favored  as  far  as 
possible  by  the  application  of  poultices,  and  as  soon 
as  fluctuation  is  detected  the  bubo  should  be  opened 
in  the  method  laid  down  in  the  chapter  on  chan- 
croidal buboes,  care  being  taken  that  all  sinuses  are 


TREATMENT  OF   GONORRHCEA.  195 

freely  laid  open  whenever  and  wherever  they  present 
themselves.  The  pus  of  such  buboes  is  always 
laudable  and  never  contagious  ;  indeed,  they  are 
nothing  more  than  abscesses  of  glandular  or  peri- 
glandular tissues.  Should  the  gland  itself  suppurate, 
recovery  may  be  hastened  by  its  removal  either  with 
the  knife  or  ligature. 

Warts,  or  the  broad  condylomata,  as  they  are  some- 
times called,  if  small  and  pedunculated,  may  be 
snipped  off  with  scissors  and  their  bases  touched 
v/ith  strong  nitric  or  acetic  acid.  When  they  are 
large,  or  seated  upon  a  broad  base,  they  should  be 
painted  with  strong  acetic  acid,  and  dusted  over  with 
powdered  alum,  or  with  the  dried  sulphate  of  iron, 
mixed  with  equal  parts  of  lycopodium.  When  very 
exuberant  and  large,  especially  in  those  cases  which 
occur  in  both  sexes  on  the  nates  and  perineum,  I  have 
often  injected  two  or  three  minims  of  glacial  acetic 
acid  into  the  substance  of  the  wart  with  benefit.  It 
shrivels  up  the  growth  with  surprising  rapidity,  and, 
if  properly  used,  injecting  but  a  few  drops  at  a  time, 
is  not  attended  with  any  danger  ;  at  the  most,  an 
abscess  is  the  worst  result  that  will  follow,  unless,  of 
course,  the  acid  is  used  recklessly  and  beyond  the 
bounds  of  prudence.  But  one  point  I  wish  particu- 
larly to  im.press  upon  your  minds  in  the  treatment 
of  these  affections  :  keep  the  parts  dry  and  clean  ;  it  is 
four-fifths  of  the  treatment. 

Herpes,  when  slight,  is  best  treated  by  powdering 


196  VENEREAL   DISEASES. 

the  parts  with  calomel,  lycopodium,  calomine,  or 
some  such  dressing  ;  if  they  show  any  tendency  to 
ulcerate,  touch  them  lightly  with  the  solid  nitrate  of 
silver,  and  finish  the  treatment  with  the  dry  dressing 
above  advised.  Do  not  use  wet  dressings  ;  they  only 
serve  to  macerate  the  epithelium  and  keep  the  parts 
in  a  condition  of  moisture  unfavorable  to  recovery. 

Where  complicated  with  digestive  troubles,  these 
latter  must  be  treated  by  the  remedies  applicable  to 
such  diseases. 


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